Mass. Gen. Laws ch. 176M, sec. 3 — MA Code / Part I / Title XXII / Chapter 176M / Section 3
Exclusion from coverage; open enrollment period
Status: in_force

Section 3. (a) No carrier, with respect to an eligible individual or eligible dependent desiring to enroll in any guaranteed issue health plan, may decline to offer such coverage to, or deny enrollment of, any such individual or dependent except as otherwise allowed in this section, nor impose any pre-existing condition exclusion with respect to any guaranteed issue health plan except as otherwise allowed in this section, nor impose any waiting period in any guaranteed issue health plan except as otherwise allowed in this section through June 30, 2007. A carrier shall not impose a preexisting condition exclusion or waiting period for Trade Act/HCTC–Eligible Persons. (b) In calendar year nineteen hundred and ninety-seven, the carrier shall enroll eligible individuals into guaranteed issue health plans during an open enrollment period commencing June first and ending July thirty-first with coverage to become effective September first. The commissioner may postpone said open enrollment period and effective date of coverage should a substantial number of carriers, due to substantial administrative delay, be unable to enroll eligible individuals into a guaranteed issue health plan during the open enrollment period commencing June first and ending July thirty-first; provided, however, that any carrier that is unable to enroll eligible individuals into a guaranteed issue health plan during the open enrollment period beginning June first and ending July thirty-first, for reasons other than substantial administrative delay, may be subject to a fine of one thousand dollars for every day in which it is unable to enroll such eligible individuals in said guaranteed issue health plan and any other penalties available under this chapter. (1) A carrier shall enroll any person who meets the requirements of an eligible individual as defined in section 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. section 300gg–41(b), into a guaranteed issue health plan if such person requests guaranteed issue coverage within 63 days of termination of any prior creditable coverage. Coverage shall become effective within 30 days of the date of application, subject to reasonable verification of eligibility. (2) A carrier shall enroll any eligible individual who does not meet the requirements of an eligible individual as defined in section 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. section 300gg–41(b), into a guaranteed issue health plan; provided, however, that a carrier may impose a pre-existing condition exclusion for no more than six months or a waiting period, which shall be applied uniformly without regard to any health status-related factors, for no more than six months following the individual's effective date of coverage. If a policy includes a waiting period, emergency services shall be covered to the same extent that emergency services are covered during a waiting period under chapter 176J. In determining whether a pre-existing condition exclusion or a waiting period applies, all health benefit plans shall credit the time such person was covered under prior creditable coverage provided by a carrier if the previous coverage was continuous to a date not more than 63 days prior to the date of the request for the new coverage and if the previous coverage was reasonably actuarially equivalent to the new coverage. Coverage shall become effective within 30 days of the date of application. The commissioner shall promulgate regulations relative to pre-existing condition exclusions and waiting periods permissible pursuant to this section. (c) Carriers may utilize intermediaries, as defined in section one, to offer guaranteed issue health plans to eligible individuals. Fees charged by such intermediaries shall be reasonable and shall not serve as a barrier to the purchase of insurance under this chapter. (d) A carrier shall no longer offer, sell or deliver a health plan to a person to whom it does not have such an obligation under an individual policy, contract or agreement with an employer or through a trust or association; provided, however, that a closed guaranteed issue plan or a closed health plan shall be subject to all the other requirements of this chapter. A carrier shall be obligated to renew a closed guarantee issue health plan and a closed plan. A carrier may discontinue a closed guarantee issue health plan or a closed under regulations promulgated by the commissioner. (e) Carriers shall notify all members, at the direction of the commissioner, at least once annually, of all health benefit plans and pursuant premiums for which the member is eligible under chapter 176J. (f) A carrier shall not be required to issue or renew a guaranteed issue health plan to any eligible individual if the carrier can demonstrate any of the following (1) that the acceptance of applications would create for the carrier a condition of financial impairment, and the carrier demonstrates the same to the commissioner; (2) that the eligible individual does not meet a health maintenance organization's requirements regarding residence or employment within the health maintenance organization's approved service area; or (3) that within an area, where the health maintenance organization reasonably anticipates, and demonstrates 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 individual because of its obligation to existing contract holders and enrollees; provided, however, that such a health maintenance organization shall not offer coverage in the applicable area to any new applicants for coverage, whether they be applicants for group or nongroup coverage, until the later of ninety days after each such refusal or the date on which the health maintenance organization notifies the commissioner that it has regained capacity to deliver services to eligible individuals. (g) A carrier shall not be required to issue or renew a guaranteed issue health plan to an eligible individual, and may cancel a previously issued guaranteed issue health plan, if (1) the individual failed to pay the required premium for any health benefit plan on a timely basis, (2) the individual committed fraud or misrepresented whether he qualifies as an eligible individual, (3) the individual failed to comply in a material way with the provisions of the health benefit plan, the member contract, or the subscriber agreement, or (4) the individual failed to comply with the carrier's reasonable request for information in accordance with subsection (d) of section four in the application for coverage under a guaranteed issue health plan. A premium shall be considered to have been paid on a timely basis if it is paid within sixty days. (h) A carrier that decides to terminate coverage for all eligible individuals enrolled in a specific guaranteed issue plan shall notify the commissioner of insurance no later than 180 days prior to terminating coverage under that guaranteed issue health benefit plan. A carrier may not terminate a guaranteed issue health plan if such termination would cause the carrier to violate subsection (b) of section two. A carrier who terminates guaranteed issue health plans pursuant to this subsection shall not issue any guaranteed issue health benefit plans pursuant to this subsection for a period of five years; provided, however, that the commissioner, in his discretion, may allow a carrier to re-enter the nongroup market sooner.

Section 3. (a) No carrier, with respect to an eligible individual or eligible dependent desiring to enroll in any guaranteed issue health plan, may decline to offer such coverage to, or deny enrollment of, any such individual or dependent except as otherwise allowed in this section, nor impose any pre-existing condition exclusion with respect to any guaranteed issue health plan except as otherwise allowed in this section, nor impose any waiting period in any guaranteed issue health plan except as otherwise allowed in this section through June 30, 2007. A carrier shall not impose a preexisting condition exclusion or waiting period for Trade Act/HCTC–Eligible Persons.

(b) In calendar year nineteen hundred and ninety-seven, the carrier shall enroll eligible individuals into guaranteed issue health plans during an open enrollment period commencing June first and ending July thirty-first with coverage to become effective September first. The commissioner may postpone said open enrollment period and effective date of coverage should a substantial number of carriers, due to substantial administrative delay, be unable to enroll eligible individuals into a guaranteed issue health plan during the open enrollment period commencing June first and ending July thirty-first; provided, however, that any carrier that is unable to enroll eligible individuals into a guaranteed issue health plan during the open enrollment period beginning June first and ending July thirty-first, for reasons other than substantial administrative delay, may be subject to a fine of one thousand dollars for every day in which it is unable to enroll such eligible individuals in said guaranteed issue health plan and any other penalties available under this chapter.

(1) A carrier shall enroll any person who meets the requirements of an eligible individual as defined in section 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. section 300gg–41(b), into a guaranteed issue health plan if such person requests guaranteed issue coverage within 63 days of termination of any prior creditable coverage. Coverage shall become effective within 30 days of the date of application, subject to reasonable verification of eligibility.

(2) A carrier shall enroll any eligible individual who does not meet the requirements of an eligible individual as defined in section 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. section 300gg–41(b), into a guaranteed issue health plan; provided, however, that a carrier may impose a pre-existing condition exclusion for no more than six months or a waiting period, which shall be applied uniformly without regard to any health status-related factors, for no more than six months following the individual's effective date of coverage. If a policy includes a waiting period, emergency services shall be covered to the same extent that emergency services are covered during a waiting period under chapter 176J. In determining whether a pre-existing condition exclusion or a waiting period applies, all health benefit plans shall credit the time such person was covered under prior creditable coverage provided by a carrier if the previous coverage was continuous to a date not more than 63 days prior to the date of the request for the new coverage and if the previous coverage was reasonably actuarially equivalent to the new coverage. Coverage shall become effective within 30 days of the date of application. The commissioner shall promulgate regulations relative to pre-existing condition exclusions and waiting periods permissible pursuant to this section.

(c) Carriers may utilize intermediaries, as defined in section one, to offer guaranteed issue health plans to eligible individuals. Fees charged by such intermediaries shall be reasonable and shall not serve as a barrier to the purchase of insurance under this chapter.

(d) A carrier shall no longer offer, sell or deliver a health plan to a person to whom it does not have such an obligation under an individual policy, contract or agreement with an employer or through a trust or association; provided, however, that a closed guaranteed issue plan or a closed health plan shall be subject to all the other requirements of this chapter. A carrier shall be obligated to renew a closed guarantee issue health plan and a closed plan. A carrier may discontinue a closed guarantee issue health plan or a closed under regulations promulgated by the commissioner.

(e) Carriers shall notify all members, at the direction of the commissioner, at least once annually, of all health benefit plans and pursuant premiums for which the member is eligible under chapter 176J.

(f) A carrier shall not be required to issue or renew a guaranteed issue health plan to any eligible individual if the carrier can demonstrate any of the following (1) that the acceptance of applications would create for the carrier a condition of financial impairment, and the carrier demonstrates the same to the commissioner; (2) that the eligible individual does not meet a health maintenance organization's requirements regarding residence or employment within the health maintenance organization's approved service area; or (3) that within an area, where the health maintenance organization reasonably anticipates, and demonstrates 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 individual because of its obligation to existing contract holders and enrollees; provided, however, that such a health maintenance organization shall not offer coverage in the applicable area to any new applicants for coverage, whether they be applicants for group or nongroup coverage, until the later of ninety days after each such refusal or the date on which the health maintenance organization notifies the commissioner that it has regained capacity to deliver services to eligible individuals.

(g) A carrier shall not be required to issue or renew a guaranteed issue health plan to an eligible individual, and may cancel a previously issued guaranteed issue health plan, if (1) the individual failed to pay the required premium for any health benefit plan on a timely basis, (2) the individual committed fraud or misrepresented whether he qualifies as an eligible individual, (3) the individual failed to comply in a material way with the provisions of the health benefit plan, the member contract, or the subscriber agreement, or (4) the individual failed to comply with the carrier's reasonable request for information in accordance with subsection (d) of section four in the application for coverage under a guaranteed issue health plan. A premium shall be considered to have been paid on a timely basis if it is paid within sixty days.

(h) A carrier that decides to terminate coverage for all eligible individuals enrolled in a specific guaranteed issue plan shall notify the commissioner of insurance no later than 180 days prior to terminating coverage under that guaranteed issue health benefit plan. A carrier may not terminate a guaranteed issue health plan if such termination would cause the carrier to violate subsection (b) of section two. A carrier who terminates guaranteed issue health plans pursuant to this subsection shall not issue any guaranteed issue health benefit plans pursuant to this subsection for a period of five years; provided, however, that the commissioner, in his discretion, may allow a carrier to re-enter the nongroup market sooner.