Code of Massachusetts Regulations
805 CMR - GROUP INSURANCE COMMISSION
Title 805 CMR 9.00 - ELIGIBILITY AND PARTICIPATION
Section 9.04 - Individual and Family Health Coverage

Universal Citation: 805 MA Code of Regs 805.9

Current through Register 1531, September 27, 2024

(1) Employees who elect Individual Health Coverage at the time of hire may later elect Family Health Coverage due to a change in family status (e.g., marriage or adoption, spouse's loss of other coverage), subject to verifying documentation acceptable to the Commission including, but not limited to, marriage and birth certificates. Verification that requires translation shall be at the applicant's expense. The effective date of the family status change is determined by the Commission.

(2) Employees, Retirees, and Surviving Spouses whose dependents cease to be eligible for Commission coverage must notify the Commission within 30 days of such occurrence. The Commission shall determine the effective date of dependents' coverage termination.

(3) Unless making such a request during the annual open enrollment period, Employees, Retirees, or Surviving Spouses may change their Family Coverage to Individual Coverage only by providing proof of their Dependents' other coverage or a change in family circumstance as described in 805 CMR 9.04. The Commission's decisions relating to coverage termination requests are final and binding.

(4) Divorce and Remarriage.

(a) If a former Spouse is eligible under the terms of a divorce decree and enrolled under the insured's family plan, coverage for the former Spouse under the insured's family plan will end upon the remarriage of either the Insured or former Spouse. The former Spouse may be eligible for a divorced Spouse rider or COBRA coverage, as determined by the Commission, depending upon the language in the final divorce decree, separation agreement or court order as applicable.

(b) Former spouses of Employees or Retirees cannot be terminated from Commission health coverage for reasons of additional cost when their children are no longer enrolled in the coverage, unless the divorced Employee or Retiree has remarried or the divorce agreement expressly defines such a scenario as constituting additional cost.

(c) All members are obligated to notify the Commission of divorces and remarriages within 60 days of the event and provide supporting documentation for the event. All members are responsible for updating the Commission's records with all court orders, modifications, and other pertinent information or legal documents surrounding the separation or divorce within 60 days of the event. Failure to timely provide the applicable documentation or address updates may result in termination of Commission coverage, money owed, and/or other consequences.

(d)
1. In the event that a remarriage is not timely reported to the Commission and benefits are provided to an ineligible former Spouse, the Employee may be terminated from Commission coverage until such time as the back premiums or claims expenses are repaid.

2. If an ex-spouse becomes ineligible for coverage under the employee's policy by operation of law, there will be no refund or credits of premiums paid.

(5) For an Employee, Retiree, or Surviving Spouse with Family Health Coverage to enroll in a plan with a defined geographical enrollment area, all enrolled family members, including all covered Dependents, should reside in the plan's service area. Children younger than 19 years old and Students are deemed to reside with the Employee, Retiree, or Surviving Spouse on whose plan they are Dependents, unless that Employee, Retiree, or Surviving Spouse is not the Child's or Student's custodial parent. In that case, Children younger than 19 years old and Students are deemed to reside with their custodial parent. Benefits for dependents residing outside a plan's service area are determined by the plan. In the event that an enrolled family member no longer resides in the plan's service area, the Employee, Retiree, or Surviving Spouse should enroll in a plan with an appropriate service area or with no geographical restrictions. Plan changes must be made within 60 days of the change in residence.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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