Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 66.00 - Small Group Health Insurance
Section 66.04 - Minimum Coverage Standards

Universal Citation: 211 MA Code of Regs 211.66

Current through Register 1531, September 27, 2024

(1) Offerings and Open Enrollment.

(a) Unless otherwise provided in 211 CMR 66.04, every Carrier shall make available to every Eligible Individual and every Eligible Small Business a certificate that evidences coverage for every Health Benefit Plan that it provides to any other Eligible Individual or Eligible Small Business whether issued or renewed to a trust, association or other entity that is not a Group Health Plan, as well as to their Eligible Dependents. Additionally, a Carrier may offer certain Health Benefit Plans, including Catastrophic Health Benefit Plans and Child-only Health Benefit Plans. Every Carrier must accept for enrollment any Eligible Individual or Eligible Small Business that seeks to enroll in a Health Benefit Plan as provided herein; however, a Carrier shall only contract to sell a Health Benefit Plan to cover an Eligible Individual and Eligible Dependents during an annual open enrollment period, except as follows:
1. A Carrier shall enroll an Eligible Individual into a health plan if such individual requests coverage within 63 days of termination of any prior coverage that meets the ACA minimum essential coverage requirements.

2. A Carrier shall enroll an Eligible Individual into a health plan if such individual requests coverage within 63 days of experiencing another qualifying or ACA triggering event, and in doing so the Carrier must comply with the ACA and Exchange enrollment requirements, as applicable.

3. A Carrier shall enroll an Eligible Individual who has been granted a waiver by the Office of Patient Protection.

(b) Coverage issued to Eligible Small Businesses under 211 CMR 66.04(1)(a) shall become effective within 30 days of a Carrier's receipt of a completed application.

(c) Upon the request of an Eligible Small Business or Eligible Individual, a Carrier shall provide that Eligible Small Business or Eligible Individual with a sample of Health Benefit Plans and prices and, upon request, a price for every Health Benefit Plan that it makes available to any Eligible Small Business or Eligible Individual. The Carrier may satisfy such a request for information on Health Benefit Plan offerings by referring the Eligible Small Business or Eligible Individual to resources where the information can be accessed including, but not limited to, an internet website, and the term internet website shall include intranet website and electronic mail or e-mail. The Carrier must provide free of charge a paper copy of this information if the Eligible Small Business or Eligible Individual requests such a paper copy. The Carrier shall provide a toll-free telephone number for the Eligible Individual and Eligible Small Business to call with any questions or requests.

(d) A Carrier may decide to limit its sale of any Health Benefit Plan to Eligible Small Businesses by requiring that an Eligible Small Business have Eligible Employees that reside or work in the Carrier's service area; provided, however, the Eligible Small Business shall not make a smaller health insurance premium contribution percentage amount to an employee than the employer makes to any other employee who receives an equal or greater total hourly or annual salary for each Health Benefit Plan for all employees. Notwithstanding the foregoing, a Carrier may sell, issue, market or deliver a Health Benefit Plan to an employer that establishes separate contribution percentages for employees covered by collective bargaining agreements.

(e) If a Carrier is not accepting every new Eligible Small Group or Eligible Individual, it may not accept any new Eligible Small Groups or Eligible Individuals either directly, through an association or through an Intermediary or through the Connector. However, if a Carrier issued a health insurance product which is not available to Eligible Small Groups or Eligible Individuals but is available to a group with 51 or more employees and the size of that group declined to 50 or fewer employees during the term of the policy, the Carrier is not required to make that particular health insurance product available to Eligible Small Groups or Eligible Individuals.

(f) A Carrier may deny an Eligible Individual or an Eligible Small Group of five or fewer Eligible Employees enrollment in a Health Benefit Plan unless the Eligible Individual or the Eligible Small Group enrolls through an Intermediary or through the Connector, provided that the Carrier complies with all of the following requirements:
1. For Eligible Individuals and Eligible Small Groups of five or fewer Eligible Employees, every Carrier must make coverage available either directly or through an Intermediary or through the Connector; however, such coverage shall be at no higher cost than if the Eligible Individual or Eligible Employer had purchased the coverage directly from the Carrier.

2. No Carrier may require an Eligible Individual or an Eligible Small Group of five or fewer Eligible Employees to join an Intermediary if the Intermediary has unreasonable barriers to membership including, but not limited to, unreasonable fees or unreasonable membership requirements. If an Eligible Individual or a Eligible Small Group is precluded from joining an Intermediary due to unreasonable membership barriers, the Carrier must enroll the Eligible Individual or Eligible Small Group directly. Nothing in 211 CMR 66.04(1)(f) shall prohibit a Carrier from enrolling Eligible Individuals or Eligible Small Groups directly or through the Connector.

3. If an Eligible Individual or an Eligible Small Group of five or fewer Eligible Employees elects to enroll through an Intermediary or through the Connector, a Carrier may not deny that Eligible Small Group enrollment.

4. The Carrier must implement the requirements in 211 CMR 66.04(1)(f) consistently, treating all similarly situated individuals or groups in a similar manner.

5. Any Carrier that enrolls Eligible Individuals or Eligible Small Businesses through an Intermediary or through the Connector must comply with all provisions of 211 CMR 66.00.

6. Nothing in 211 CMR 66.04(1)(f) prohibits an Eligible Individual or an Eligible Small Business with six to 50 employees from electing to enroll through an Intermediary or through the Connector for coverage under a Health Benefit Plan.

7. Nothing in 211 CMR 66.04(1)(f) permits a Carrier to require an Eligible Small Business with six to 50 employees to enroll through an Intermediary or through the Connector for coverage under a Health Benefit Plan.

(g) A Carrier may implement a policy for issuance of a Health Benefit Plan to an Eligible Individual who has a demonstrated history of canceling his or her coverage under a Health Benefit Plan with any Carrier prior to the end of that Eligible Individual's contract renewal period including, but not limited to, a policy that said Eligible Individual be required to pay a portion of his or her annual premium in advance, provided that said policy is submitted to the Division for approval prior to implementation. A Carrier is not required to issue a Health Benefit Plan to an Eligible Individual or an Eligible Small Business if the Carrier can demonstrate to the satisfaction of the Commissioner that:
1. the Eligible Individual or Eligible Small Business has made at least three or more late payments in a 12-month period; or

2. within the prior 12 months, the Eligible Individual or Eligible Small Business has committed fraud, misrepresented the eligibility of an employee or of an individual, or misrepresented information necessary to determine group size, group Participation Rate, the group premium rate, or individual rate; or

3. within the prior 12 months, the Eligible Individual or Eligible Small Business has failed to comply in a material manner with a Health Benefit Plan provision, including, failure to provide information necessary to determine eligibility, and, for an Eligible Small Business, Carrier requirements for employer group premium contributions; but

4. nothing in 211 CMR 66.04(1)(g)1. through 3. may be used by a Carrier to refuse acceptance of an Eligible Small Business solely because the Eligible Small Business offers multiple Health Benefit Plans at the same time.

(h) A Carrier may request information from other Carriers regarding the items listed in 211 CMR 66.04(1)(g) provided that the request does not violate any applicable state or federal law. The Carrier receiving such a request from another Carrier may provide the information consistent with state or federal law.

(i) A Carrier is not required to issue a Health Benefit Plan to an Eligible Small Business or Eligible Individual if the Eligible Small Business or Eligible Individual fails to comply with reasonable requests by the Carrier for information necessary to verify the application for coverage including, but not limited to, information regarding the prior health insurance coverage of the Eligible Small Business or Eligible Individual. Requests for information may also include information reasonably necessary for the Carrier to determine whether the small business is an Eligible Small Business or whether a person is an Eligible Employee or an Eligible Individual.

(j) Except during an open enrollment period and as otherwise required by the ACA, a Carrier is not required to issue a Health Benefit Plan to an Eligible Small Business if the Carrier can demonstrate, to the satisfaction of the Commissioner, that the small business fails at the time of issuance or renewal to meet a Participation Rate requirement established under the definition of Participation Rate. However, if an Eligible Small Business does not meet a Carrier's minimum Participation Rate requirement, the Carrier may separately rate each employee as an Eligible Individual.

(k) A Carrier is not required to issue a Health Benefit Plan to an Eligible Individual or Eligible Small Business if acceptance of an application or applications would create for the Carrier a condition of Financial Impairment. The Carrier must file with the Commissioner at least 30 days in advance of any such denial, or as soon as the Carrier's financial position becomes known to the Carrier, a certified statement by the Chief Financial Officer attesting to the Carrier's presentation of information evidencing a likely conclusion of Financial Impairment and accompanied by supporting documentation. Any Carrier found to be in a condition of Financially Impairment by the Commissioner must immediately cease issuing Health Benefit Plans on an initial basis to Eligible Individuals and Eligible Small Businesses in accordance with the provisions of 211 CMR 66.04(4).

(l) Every Carrier must apply participation and employer contribution requirements in a uniform manner to all groups of the same size. Carriers may not increase participation or employer contribution requirements where the size of the group has changed until the group's renewal date of the Health Benefit Plan.

(m) Any Carrier that denies coverage to an Eligible Small Business or Eligible Individual under the provisions of 211 CMR 66.04 must:
1. provide to the Eligible Small Business or Eligible Individual, in writing, the specific reason(s) for the denial of coverage; and

2. make available to the Commissioner, upon request, the documentation for the denial.

(n) An HMO is not required to accept applications from or offer coverage:
1. to an Eligible Individual or an Eligible Small Group, where the Eligible Individual or Eligible Small Group is not physically located in the HMO's approved service area; or

2. within an area, where the HMO reasonably anticipates, and receives prior approval by demonstrating to the satisfaction of the Commissioner, that it will not, within that area, have the capacity in its network of providers to deliver services adequately to the Members because of its obligations to existing contract holders and enrollees. The HMO may not offer coverage in that area to any new cases of individuals or business groups of any size until the later of 90 days after each refusal or the date on which the Carrier notifies the Commissioner that it has regained capacity to deliver services to Eligible Small Businesses and Eligible Employees.

(o) A Carrier that offers a Health Benefit Plan that:
1. provides or arranges for the delivery of health care services through a closed network of health care providers; and

2. has reported in its annual Membership filing that as of the close of the preceding calendar year that a combined total of 5,000 or more Eligible Individuals, Eligible Employees and Eligible Dependents, were enrolled in Health Benefit Plans sold, issued, delivered, made effective or renewed by the Carrier to Eligible Small Businesses or Eligible Individuals, shall, by no later than January 1st of the following year, offer to all Eligible Individuals and small businesses in at least one geographic area at least one plan with either a limited network of providers or a plan in which providers are tiered and Member cost sharing is based on the tier placement that meets the standards of 211 CMR 152.04: Tiered Provider Network Plans. The goal is for these plans to be available throughout the Commonwealth. For the purpose of 211 CMR 66.04(1)(o)2., "geographic area" shall mean the largest metropolitan region in a Carrier's service area, subject to the approval of the Commissioner. A Carrier may use a plan containing multiple networks to meet the geographic area standard described in 211 CMR 66.04(1)(o)2. The Benefit Level Rate Adjustment Factor of this plan will be such that this plan's Eligible Small Group Base Premium shall be at least 14% lower than the Group Base Premium Rate of the Carrier's most actuarially similar plan with a non-limited or non-tiered network of providers (a "32A Plan"). Carriers shall only classify or reclassify providers in a Carrier's 32A Plan by Benefit Level tiers based on quality performance as measured by the standard quality measure set as authorized under M.G.L. c. 12C, § 14(a) and by cost performance as measured by health status adjusted total medical prices and relative prices. When applicable quality measures are not available, a Carrier shall tier providers either solely on adjusted total medical expenses or relative prices or both.

3. If the Carrier applies for and obtains written approval from the Commissioner by no later than May 1st of the year in which the carrier is first required to offer a 32A Plan, then the Carrier may delay implementation of its 32A Plan as set forth in 211 CMR 66.04(1)(o)2.

(p) A Carrier that offers a Health Benefit Plan that has reported in its annual Membership filing that, as of the close of the preceding calendar year, a combined total of 5,000 or more Eligible Individuals, Eligible Employees and Eligible Dependents, were enrolled in Health Benefit Plans sold, issued, delivered, made effective or renewed by the Carrier to Eligible Small Businesses or Eligible Individuals, shall be required, as a condition of continued offer of coverage to Eligible Small Business and Eligible Individuals outside of Group Purchasing Cooperatives, to respond to all documents from certified Group Purchasing Cooperatives requesting submission of product and rate proposals for offer by the Group Purchasing Cooperative to eligible Members of the qualified associations. The responses will be submitted to the Group Purchasing Cooperatives in a timely and complete manner.

(2) Reduced or Selective Network Plans; Tiered Network Plans.

(a) Unless the Carrier has a waiver from the Commissioner, any Carrier that offers a Health Benefit Plan that:
1. provides or arranges for the delivery of health care services through a closed network of health care providers; and

2. as of the close of any preceding calendar year, has a combined total of 5,000 or more Eligible Individuals, Eligible Employees and Eligible Dependents, who are enrolled in Health Benefit Plans sold, issued, delivered, made effective or renewed to Eligible Small Businesses or Eligible Individuals, shall offer to all Eligible Individuals and Eligible Small Businesses in at least one geographic area at least one plan with either:
a. a reduced or selective network of providers; or

b. a plan in which providers are tiered and Member cost sharing is based on the tier placement of the provider.

A tiered network plan shall only include variations in Member cost-sharing between provider tiers which are reasonable in relation to the premium charged and ensure adequate access to covered services. Carriers shall tier providers, or type of service if a "smart tier" plan, based on quality performance as measured by the standard quality measure set and by cost performance as measured by health status adjusted total medical expenses and relative prices, according to the Center for Health Information and Analysis. Where applicable quality measures are not available, tiering may be based solely on health status adjusted total medical expenses or relative prices or both.

(3) Eligible Employees, Eligible Individuals and Eligible Dependents.

(a) Every Carrier must provide coverage to all Eligible Employees, all Eligible Individuals, and all Eligible Dependents except:
1. in the case of a closed network HMO product, where the Eligible Employee or Eligible Individual or Eligible Dependent does not meet the HMO's requirements regarding residence or employment within the HMO's approved service area;

2. in the case of an Eligible Small Business, when an Eligible Employee seeks to enroll in a Health Benefit Plan significantly later than he or she was initially eligible to enroll.

However, an Eligible Employee or Eligible Dependent will not be considered a Late Enrollee if the individual requests enrollment within 63 days after termination of a previous Qualifying Health Plan; or a court has ordered coverage be provided for a spouse, former spouse, minor or dependent child under a covered employee's Health Benefit Plan and request for enrollment is made within 30 days after issuance of the court order.

(b) A Carrier that does not provide coverage to a late entrant because an Eligible Employee or Eligible Dependent did not meet the conditions of 211 CMR 66.04(3)(a)2., must make coverage available to that person at the Eligible Small Group's next renewal date and may not deny that person coverage at the next renewal date except for reasons otherwise allowed by 211 CMR 66.00.

(c) A Carrier may not require that a person must have worked for an unreasonable length of time in order to qualify as an Eligible Employee. For the purposes of 211 CMR 66.00, more than 90 days is considered to be an unreasonable length of time when determining employee eligibility to be offered health insurance.

(d) Nothing in 211 CMR 66.00 shall prohibit a Carrier from offering coverage in an Eligible Small Group to a person, and his or her dependents, who does not satisfy the definition of Eligible Employee, provided that the Carrier applies these standards consistently across the Eligible Small Group to all such persons and their dependents who do not meet the definition of an Eligible Employee.

(e) Nothing in 211 CMR 66.00 shall prohibit a Carrier from offering coverage to an Eligible Individual or Eligible Dependent who seeks coverage pursuant to 211 CMR 66.04(1)(a)1. through 3.

(4) Discontinuance Provisions.

(a) Filing Requirements. Notwithstanding any other provision in 211 CMR 66.04, a Carrier may deny an Eligible Individual or Eligible Small Business enrollment in a Health Benefit Plan if the Carrier certifies to the Commissioner that the Carrier intends to discontinue selling that Health Benefit Plan to new Eligible Individuals and Eligible Small Businesses.

(b) Material to Be Submitted. A Carrier that intends to discontinue selling a Health Benefit Plan to new Eligible Individuals and Eligible Small Businesses must, at least 30 days in advance of discontinuing the sale of the Health Benefit Plan, submit to the Commissioner a statement certified by an officer of the Carrier that specifies all of the following:
1. The date by which it will discontinue selling the Health Benefit Plan to all new individuals and groups.

2. The reason(s) for the discontinuance of the Health Benefit Plan.

3. A list of any other Health Benefit Plans it continues to sell in Massachusetts.

4. The number of groups and individuals covered by the discontinued Health Benefit Plan, both in Massachusetts and in its total book of business.

5. An acknowledgment that the Carrier is prohibited from selling the particular Health Benefit Plan again in Massachusetts to new individuals and groups for a period of not less than three years.

(c) The Commissioner may disapprove, within 21 days of receiving notice under 211 CMR 66.04(4)(b), a Carrier's election to discontinue the sale of the Health Benefit Plan if the Carrier fails to comply with 211 CMR 66.04(4)(b) or is in violation of 211 CMR 66.04(5).

(d) Notwithstanding any other provision in 211 CMR 66.04, Carriers are required to renew coverage, as described in 211 CMR 66.05, under an otherwise discontinued Health Benefit Plan for existing groups.

(5) In no event may a Carrier deny an Eligible Individual or Eligible Small Group enrollment in a Health Benefit Plan as part of an effort to circumvent the intent of M.G.L. c. 176J.

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