Code of Massachusetts Regulations
956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY
Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market
Section 13.07 - Reconsideration Procedures

(1) Scope of Reconsideration. The Connector will not consider any claim or issue raised in the request for reconsideration that could have been raised in the ongoing discrepancy resolution process, but that was not.

(2) Burden of Proof. The burden of proving a ground for reconsideration will be on the Carrier seeking reconsideration.

(3) First-level Review. The Connector will review the request for reconsideration. In conducting this review, the Connector will consider the Final Risk Adjustment Payments and Charges Report, along with all the data, calculations, and other evidence supporting that report. Additionally, the Connector will consider any documentary evidence included by the Carrier in its request for reconsideration. The Connector may consider other evidence that it considers to be relevant, provided that it will provide such evidence to the Carrier with a reasonable opportunity to review and comment on such evidence. The Connector may conduct this first-level review based solely on documentary evidence. The Connector will inform the Carrier of its reconsideration decision in writing.

(4) Request for Hearing. A Carrier that is aggrieved by the Connector's decision after the first-level review may file a request for hearing. The request must be in writing and must be submitted within ten calendar days after issuance of the first-level reconsideration decision.

(5) Hearing. The hearing will be conducted using the policies and procedures set forth for informal hearings pursuant to 801 CMR 1.02: Informal Fair Hearing Rules or in any administrative bulletins issued by the Connector.

(6) Conduct of Hearing. The hearing officer will not consider any issue or claim that was not raised in the request for reconsideration. The hearing officer will not accept any evidence that was not presented by the Carrier with the reconsideration request or considered by the Connector in the first-level review.

(7) Decision. The hearing officer will issue a final decision in writing. The decision of the hearing officer will be the final decision of the Connector.

(8) Adjustment. In the event the final decision would cause a change in the relative risk adjustment payment and transfers among Carriers that would have been made in a Benefit Year, the Connector will determine the level of adjustment required to be applied to each Carrier's transfer amounts, with the adjustment made to the next risk adjustment transfer after the issuance of the final decision and the conclusion of any proceedings for judicial review arising from that decision.