Eligibility for Connector Programs

(1) Eligibility for a Non-group Health Plan without Financial Assistance. To be eligible for a Non-group Health Plan without financial assistance, the individual must: (a) Be a citizen or national of the United States, or a non-citizen who is lawfully present in the United States, as defined in 45 CFR 152.2, and is reasonably expected to be a citizen, national, or a non-citizen who is lawfully present for the entire period for which enrollment is sought; (b) Not be incarcerated, other than incarceration pending the disposition of charges; and (c) Be a Resident. To be eligible for a Non-group Health Plan that is a catastrophic plan, as described at 42 USC § 18022(e), an individual must meet the above eligibility requirements and also not have reached 30 years of age before the beginning of the plan year or have a qualifying exemption from the requirement to maintain minimum essential coverage under the Internal Revenue Code, 45 CFR 155.305(h)(2), § 5000A. (2) Eligibility for a Non-group Health Plan with APTC Only. To be eligible for a Non-group Health Plan with APTC only, the individual must: (a) Meet the eligibility requirements for a Non-group Health Plan without Financial Assistance set forth in 956 CMR 12.04(1); (b) Meet the eligibility requirements for federal Advance Premium Tax Credits set forth in 45 CFR 155.305(f); and (c) Not meet the eligibility requirements for ConnectorCare set forth in 956 CMR 12.04(3). (3) Eligibility for ConnectorCare. (a) To be eligible for ConnectorCare, an individual must: 1. Have an expected Household MAGI for the year for which the individual is seeking ConnectorCare that is at or below 500% of the FPL; and 2. Meet the eligibility requirements for a Non-group Health Plan with APTC only, as set forth in 956 CMR 12.04(2)(a) and (b). (b) The eligibility determination for ConnectorCare will include a determination of the Plan Type based on the individual's Household MAGI as a percentage of the FPL for the year for which the individual is seeking ConnectorCare. Premium Assistance amounts and Cost Sharing Subsidies will vary among Plan Types, as determined by the Board. The following are the different levels of such income for each Plan Type: 1. Plan Type 1 - not in excess of 100% of the FPL; provided that for plan years beginning on or after January 1, 2026, the income level for Plan Type 1 shall be less than 100% of the FPL. 2. Plan Type 2 - more than 100% but not in excess of 200% of the FPL, except that persons at or below 150% of FPL will be in Plan Type 2A, and those over 150% and not over 200% of FPL will be in Plan Type 2B; provided that for plan years beginning on or after January 1, 2026, the income levels for Plan Type 2 shall be at least 100% but not in excess of 200% of the FPL. 3. Plan Type 3 – more than 200% but not in excess of 500% of FPL, except that: a. persons at or below 250% of the FPL will be in Plan Type 3A; b. persons above 250% of the FPL and not over 300% of the FPL will be in Plan Type 3B; c. persons above 300% of the FPL and not over 400% of the FPL will be in Plan Type 3C; and d. persons above 400% of the FPL and not over 500% of the FPL will be in Plan Type 3D. (c) Premiums for ConnectorCare. Premiums paid by ConnectorCare Enrollees within the same Plan Type may vary depending on the Health Plan selected. The differentials in Premiums for Health Plans will be determined by the Connector based on the difference in cost of the Health Plans. There will be at least one Health Plan available to Plan Type 1 and Plan Type 2A Eligible Individuals that has no Premium provided that the Enrollee chooses to elect the full amount of APTC available to that Enrollee. There will be at least one Health Plan available to Plan Types 2B and three Eligible Individuals that will cost the minimum Premium set by the Board in accordance with 956 CMR 12.12(9) provided that the Enrollee chooses to elect the full amount of APTC available to that Enrollee. (4) Eligibility for Small Group Health Plans. (a) Small Employer Eligibility to Offer Small Group Health Plans. To be an Eligible Small Employer, an Employer must: 1. Be a Small Employer; 2. Be actively engaged in business; 3. Offer at a minimum all full-time Employees, defined as all Employees who are employed on average at least 30 hours of service per week, coverage in a Small Group Health Plan; 4. Either have its principal business address in the Commonwealth and offer coverage to all its full-time employees through the Health Connector; or offer coverage to each eligible employee through a Small Business Health Options Program established under 42 USC § 18031, serving that employee's primary worksite; and 5. Meet minimum participation or contribution requirements, or both, as established by Connector policies, except that such participation and contribution requirements shall be waived during the Small Group Open Enrollment Period set forth in 956 CMR 12.11(3). (b) A Small Employer that has enrolled in coverage for its Employees shall not cease to be an Eligible Small Employer during a coverage year merelybecause the number of Employees it employs increases over 50.