Current through Register 1531, September 27, 2024
(1) Except as provided in
211
CMR 66.05(2), every Health
Benefit Plan shall be renewable as required by the Health Insurance Portability
and Accountability Act of 1996.
(2)
A Carrier is not required to renew the Health Benefit Plan of an Eligible Small
Business if the small business:
(a) has not
paid the required premiums; or
(b)
has committed fraud, misrepresented whether a person is an Eligible Employee,
or misrepresented information necessary to determine the size of a group, the
Participation Rate of a group, or the premium for a group; or
(c) failed to comply in a material manner
with Health Benefit Plan provisions including Carrier requirements regarding
employer contributions to group premiums; or
(d) fails, at the time of renewal, to satisfy
the definition of an Eligible Small Business or meet the Participation
Requirements of the Health Benefit Plan; or
(e) fails to comply with reasonable requests
to verify the information described in
211
CMR 66.04(1)(g);
or
(f) is not actively engaged in
business.
(3) A Carrier
is not required to renew the Health Benefit Plan of an Eligible Individual,
Eligible Employee, or Eligible Dependent if said person:
(a) has not paid the required
premiums;
(b) has committed fraud
or misrepresented whether he or she qualifies as an Eligible Individual,
Eligible Employee, Eligible Dependent, or misrepresented information necessary
to determine his or her eligibility for a Health Benefit Plan or for specific
health benefits;
(c) has failed to
comply in a material way with the provisions of the Health Benefit Plan, the
Member contract or the subscriber agreement including, but not limited to,
relocation of the individual, employee, or dependent, outside the service area
of the Carrier;
(d) fails, at the
time of renewal, to satisfy the definition of an Eligible Individual, Eligible
Employee, or Eligible Dependent, provided that the Carrier collects sufficient
information to make such a determination and makes such information available
to the Commissioner upon request; or
(e) has failed to comply with the Carrier's
reasonable request for information in an application for coverage.
(4) A Carrier must file with the
Commissioner any material changes in the criteria it uses under
211
CMR 66.05(2) and/or (3) to
determine the nonrenewability of a Health Benefit Plan for an Eligible Small
Business, Eligible Individual, Eligible Employee, or Eligible Dependent, as
applicable, as part of the annual filing required by
211
CMR 66.12.
(5) A Carrier must provide at least 60 days
prior notice to an Eligible Individual or Eligible Small Business of the
Carrier's intention not to renew that Eligible Individual or Eligible Small
Business's Health Benefit Plan and the specific reason(s) for the nonrenewal in
accordance with the Carrier's filed criteria. A Carrier must provide at least
90 days prior notice to affected Eligible Individuals or Eligible Small
Businesses of the Carrier's intention to discontinue offering a particular type
of Health Benefit Plan.
(6) A
Carrier that elects to nonrenew all of its Health Benefit Plans delivered or
issued for delivery to Eligible Individuals and Eligible Small Businesses in
Massachusetts:
(a) must submit to the
Commissioner, 30 days in advance of providing notice required under
211
CMR 66.05(6)(c) a statement
certified by an officer of the Carrier that specifies:
1. The date by which it will nonrenew all of
its Health Benefit Plans to all groups;
2. The reason(s) for the nonrenewal of all
Health Benefit Plans;
3. The number
of groups and individuals covered by the nonrenewed Health Benefit Plans, both
in Massachusetts and in its total book of business; and
4. An acknowledgment that the Carrier is
prohibited from writing new business in the individual and small group market
in Massachusetts for a period of five years from the date of notice to the
Commissioner, unless the Commissioner has determined, in his or her discretion,
that the Carrier is entitled to an exemption from the requirements of
211
CMR 66.05(6)(a)(4) pursuant
to 211 CMR
66.05(6)(e).
(b) The Commissioner may
disapprove, within 21 days of receiving notice under
211
CMR 66.05(6)(a), a Carrier's
election to nonrenew if the Carrier fails to comply with
211
CMR 66.05(6)(a) or is in
violation of
211
CMR 66.05(8).
(c) A Carrier must provide notice of the
decision not to renew coverage to all affected Eligible Individuals or Eligible
Small Businesses at least 180 days prior to the nonrenewal of any Health
Benefit Plan by the Carrier in the event the Commissioner has not disapproved
the Carrier's election to nonrenew;
(d) After the 180-day notification period, a
Carrier must nonrenew coverage to Eligible Individuals or Eligible Small
Businesses only on the date of renewal for each individual or small business.
and
(e) A Carrier may request a
waiver from the requirements of
211
CMR 66.05(6), if the Carrier
is a member of an insurance holding company system or health maintenance
organization holding company system as defined by M.G.L. c. 175, § 206 and
M.G.L. c. 176G, § 1 and at least one Health Benefit Plan that is
considered to be substantively similar, pursuant to M.G.L. c. 176J and
211 CMR
66.00, to the Health Benefit Plan(s) to be non-renewed
by the Carrier will continue to be offered by an affiliate of the Carrier as
defined by M.G.L. c. 175, § 206 and M.G.L. c. 176G, § 1. A waiver
provided under
211
CMR 66.05(6)(e) will be at
the Commissioner's discretion.
(7) Nothing in
211
CMR 66.05 prohibits a Carrier from canceling
during the term of the policy a Health Benefit Plan issued to an Eligible
Individual or Eligible Small Business for the reasons outlined in
211
CMR 66.05(2)(a) through (c) or (f) or (3)(a) through
(c); provided that if the Carrier cancels the
Health Benefit Plan for the reason found in
211
CMR 66.05(2)(a) or in
211
CMR 66.05(3)(a) during the
policy term, a Carrier must provide the Eligible Individual or Eligible Small
Business with any grace period as provided in the Eligible Individual's or
Eligible Small Business's Health Benefit Plan, including any prior notification
requirements.
(8) In no event may a
Carrier deny an Eligible Individual or Eligible Small Group renewal of a Health
Benefit Plan as part of an effort to circumvent the intent of M.G.L. c.
176J.
(9) In no event shall a
Carrier deny an Eligible Individual renewal of a Health Benefit Plan, except as
permitted in
211
CMR 66.05(3), provided,
however, that any Eligible Individual whose policy was issued outside of the
annual open enrollment described in
211
CMR 66.04(1) who seeks to
renew that policy must renew during the next open enrollment period.
(10) If a Carrier re-verifies the eligibility
of renewing individuals or small businesses, it shall complete the
re-verification at least 90 days prior to renewal.
