Long File Name

Covered California

Outreach and Sales Division

OutreachandSales@covered.ca.gov Page 1 of 6 June 20, 2024

Understanding Reasonable

Opportunity Period (ROP) & Auto-

Discontinuance

Guide Contents

1. Overview and Purpose ......................................................................................................................... 1

2. Timeline: ROP & Auto-Discontinuance Process ................................................................................... 2

3. Prevention: Assist Your Consumer Before ROP Auto-Discontinuance Begins .................................... 3

4. Mitigation: Assist Your Consumer During ROP Auto-Discontinuance Process .................................... 4

5. Restoring Eligibility and Reinstating Enrollment: Assist Your Consumer After ROP Termination ........ 5

1. Overview and Purpose

The Reasonable Opportunity Period (ROP) is a 95-day period during which conditionally

eligible consumers can submit verification documents and clear data inconsistencies in their

application. The ROP auto-discontinuance process identifies these conditionally eligible

consumers in an “enrolled” or “pending” status, who are past the due date for providing

documentation or other information to clear the data inconsistency. The process attempts to

re-verify consumer information with electronic data sources to clear their conditional eligibility –

and discontinues their eligibility if the verification continues to remain outstanding after the

expiration of the 95-day ROP timeframe.

As a result of impacts of the COVID-19 pandemic, in mid-2020 Covered California temporarily

provided extended time for consumers to resolve inconsistencies and paused any actions that

would have otherwise been taken. Effective April 2022, however, Covered California resumed

ROP processes, meaning that enrolled consumers must start providing the requested

documentation to resolve inconsistencies within the 95-day ROP, otherwise they will be at risk

of losing coverage or financial assistance – Advanced Premium Tax Credit (APTC) and Cost

Sharing Reductions (CSR).

Current ROP verification and auto-discontinuance categories are listed below,

but this may

increase to include other categories in the future:

Inconsistency Impact to Consumer

• Income

• Minimum Essential Coverage (MEC)

• American Indian or Alaskan Native

(AI/AN)

• Social Security Number (SSN)

• APTC and/or CSR is redetermined or discontinued.

• The consumer stays enrolled in their health plan.

• The consumer can request to have their

APTC/CSR restored.

• Citizenship

• Lawful presence

• Incarceration status

• Deceased

• Coverage terminated.

• The consumer can request to have their coverage

restored.

Covered California

Outreach and Sales Division

OutreachandSales@covered.ca.gov Page 2 of 6 June 20, 2024

Understanding Reasonable

Opportunity Period (ROP) & Auto-

Discontinuance

Certified Enrollers play a critical role in ensuring their consumers’ applications are properly and

accurately completed, with appropriate documentation submitted within required deadlines.

Please reference this guide for information, best practices, and additional linked resources to

prevent ROP Discontinuance and assist your consumer throughout the ROP Discontinuance

Process.

2. Timeline: ROP & Auto-Discontinuance Process

Days 1-5

• Consumer/enroller submits

application found to have a

data inconsistency

• Consumer/enroller

completes enrollment

• Eligibility Notice (NOD01)

sent to consumer to advise

them of eligibility and data

inconsistency

Day 45

IF NO

ACTION/RESPONSE

• Warning-Documents

Needed Notice (NOD03)

reminder to clear

inconsistency sent to

consumer

• Daily Summary Email

Alert - NOD03

Day 95 +

IF NO

ACTION/RESPONSE

• Consumer is selected for

ROP Auto-Discontinuance

batch

• Electronic sources are

checked again

• If still inconsistent, consumer

loses eligibility to Covered CA

program(s)

• Enrollment is terminated

• Eligibility Notice (NOD01) sent

to consumer to inform them of

discontinuance

• Daily Summary Email Alert -

NOD01

Note: Covered California certified enrollers must ensure that each application is fully and

truthfully completed by the consumer and that the completed application completely

discloses the circumstances of all persons included in the application. Bypassing

identification or verification requirements by uploading a “placeholder” image or entering

false ID or immigration numbers instead of approved documentation is unlawful and may

result in suspension, termination, or other legal action as needed. Covered California audits

enrollments and will take remedial action against any certified enroller that bypasses ROP.

Covered California

Outreach and Sales Division

OutreachandSales@covered.ca.gov Page 3 of 6 June 20, 2024

Understanding Reasonable

Opportunity Period (ROP) & Auto-

Discontinuance

3. Prevention: Assist Your Consumer Before ROP Auto-

Discontinuance Begins

Skipping answers, inputting incorrect document types or numbers, uploading “placeholder”

images, or answering questions incorrectly could cause electronic verifications to fail. These

actions may also violate the certified enroller agreement as well as state and federal laws.

avoid these possible outcomes, please check the following items.

1. To prevent a conditionally eligible enrollment, enter all consumer information into

the CalHEERS application accurately and completely

If the consumer’s eligibility results show they are conditionally eligible, immediately

review key application sections to confirm accurate information. Key sections include:

• Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN)

– Confirm that either an SSN or ITIN has been provided.

o If SSN or ITIN is not entered, additional steps and verification will be

required.

• Consumer’s legal name – Ensure that the consumer’s name entered in the

application matches their verification document.

• Date of Birth – Confirm that the consumer’s date of birth is accurate.

• Citizenship questions – Select the responses to the citizenship questions that

accurately reflect the consumer’s citizenship or immigration status.

• If the consumer has Citizenship or Lawful Presence documents, select the

appropriate responses and document type. Fill in all document numbers,

expiration dates, and status accurately and completely.

2. Eligibility Notice (NOD01)

Consumers with a data inconsistency will receive an Eligibility Notice (NOD01) informing

them they have been found to be conditionally eligible for Covered California and/or

financial assistance. The notice will let them know what document(s) they need to submit

to clear the inconsistency, with a due date and options for submitting the document(s)

(e.g., upload, mail, fax). Check the consumer’s Documents and Correspondence page.

 Resource: CalHEERS Online Application for Certified Enrollers

 Resource: Documents to Confirm Eligibility includes information on acceptable

documents, including locating appropriate numbers.

 Resource: Daily Summary Email Notices Guide for Certified Enrollers

 Resource: Acceptable Documents to Verify Identity Guide

Covered California

Outreach and Sales Division

OutreachandSales@covered.ca.gov Page 4 of 6 June 20, 2024

Understanding Reasonable

Opportunity Period (ROP) & Auto-

Discontinuance

4. Mitigation: Assist Your Consumer During ROP Auto-

Discontinuance Process

If a consumer has not provided required information or documents during the first 45 days of

the ROP to clear the inconsistency, a new notice and alert will be generated. Please check the

following items:

1. Warning – Documents Needed Notice (NOD03)

The consumer will receive a Warning-Documents Needed Notice (NOD03) to remind

them to submit their required documents. This notice will generate 45 days after the

NOD01 was sent. Check the consumer’s Documents and Correspondence page.

2. Daily Summary Email – Secure Mailbox

An alert for the certified enroller will appear in the daily summary email the day after the

NOD03 notice has generated. This alert will advise the enroller that their consumer may

lose eligibility and/or enrollment. Please reach out to the consumer immediately to help

them clear the data inconsistency before they run out of time.

3. Additional Tool: Book of Business (BoB) Extract

Utilize the BoB extract to check if any of your consumers are at risk of having their

enrollment terminated due to an outstanding inconsistency. In the BoB Excel file, go to

the column for “CCP Eligibility Status” and filter for “Conditionally Eligible” (Column “Z”

on the formatted report; Column “V” on the Details-only report). A consumer that shows

in your BoB as “Conditionally Eligible” means they are still pending one or more

verification status and require additional assistance.

 Resource: Daily Summary Email Notices Guide for Certified Enrollers

 Resource: Book of Business Export guide includes directions on how to export the

BoB.

Covered California

Outreach and Sales Division

OutreachandSales@covered.ca.gov Page 5 of 6 June 20, 2024

Understanding Reasonable

Opportunity Period (ROP) & Auto-

Discontinuance

5. Restoring Eligibility and Reinstating Enrollment: Assist Your

Consumer After ROP Termination

If a consumer’s enrollment has been terminated due to failure to clear the data inconsistency

within the 95-day ROP, they still have 30 calendar days from the date of termination to provide

documentation to restore eligibility and request reinstatement with no gap in coverage. After 30

days, the consumer will need a new Qualifying Life Event and must choose a new plan with a

future effective start date. Retroactive effective start dates will not be granted to remove gaps

in coverage. To help your consumer, please check and do the following:

1. Review and confirm the application information has been entered accurately and

completely

Use the Report a Change (RAC) functionality in CalHEERS to correct the consumer’s

information in the application. A RAC correction will usually allow the consumer’s data to

be E-Verified and restore their eligibility. Then, contact the Agent/CEC Service Center for

assistance with reinstating the original enrollment (see #3 below).

Note: If a RAC restores eligibility and the consumer‘s application no longer shows

“Conditional Eligibility”, DO NOT re-enroll them with a new effective date as this will

cause incorrect changes in premium and will negatively impact the consumer’s

deductible and out-of-pocket maximum for the remainder of the benefit year.

Example: A consumer may have been marked as a “Citizen” and not marked as

“Naturalized or Derived Citizenship Status” but then provided an Employment

Authorization Card. The application would need to be corrected to show the consumer is

a not a “Citizen” but they in fact have lawful presence, so the fields for immigration

documents are displayed to be edited. For additional information regarding the

Citizenship and Lawful Presence section of the application please see pages 32-34 of

the CalHEERS Online Application for Certified Enrollers.

2. Check the consumer’s Documents and Correspondence Page to confirm the

required documents have been uploaded.

If a consumer has not provided documents, notify them of their obligation to provide the

appropriate documents and the consequences for failing to do so. Reference our

Document Upload Guide to assist consumers with uploading verification documents.

Covered California

Outreach and Sales Division

OutreachandSales@covered.ca.gov Page 6 of 6 June 20, 2024

Understanding Reasonable

Opportunity Period (ROP) & Auto-

Discontinuance

3. Contact the Agent/CEC Service Center for assistance with restoring eligibility and

enrollment

Depending on the termination date, restoring coverage may require an escalation.

Escalations may take up to 10 business days for processing.

Note: Do not contact Qualified Health Plans (carriers), as they are unable to process

reinstatements for these cases; only Covered California can help with consumer

eligibility matters.

 Resource: CalHEERS Online Application for Certified Enrollers

 Resource: Document Upload Guide to assist consumers with uploading verification

documents.

 Resource: Qualifying Life Events

 Resource: Agent Service Center Operating Hours

Deferred Action for Childhood Arrivals (DACA) recipients are not considered lawfully present

for the purposes of Covered California eligibility and do not qualify to be reinstated into

Covered California health plans. As a result, they may be terminated for ROP since Citizenship

and Lawful Presence have been added to the terminations. DACA recipients, however, may

qualify for full-scope Medi-Cal depending on their income and can apply for Medi-Cal through

Covered California or their local county Medi-Cal office.

Agent Code of Conduct; Agency Agreement; Non-Monetary Agreement