Premiums, Delinquency, and Reinstatement

(1) Enrollee and Small Employer Premiums. Enrollees who are assessed a Premium and Small Employers are responsible for monthly payments that must be paid on or before a due date set by the Connector. The Connector will establish and maintain multiple convenient payment methods for Enrollees and Small Employers. The Connector will transmit Premium payments received from Enrollees or Small Employers to the Health Plans in which they are enrolled. (2) Delinquent Enrollee Premiums for Non-group Health Plans without Financial Assistance. An Enrollee in a Non-group Health Plan without Financial Assistance who fails to pay a monthly Enrollee Premium in full by the payment due date will be considered delinquent and will be notified when the account is past due. This notice of delinquency will inform the Enrollee that, if payment of all outstanding Premium is not received in full on or before the payment due date indicated in the notice, then the coverage will be terminated retroactively to the last day of the last month for which the Enrollee has paid for coverage in full. (3) Termination from a Non-group Health Plans without Financial Assistance for Failure to Pay Enrollee Premiums. If a delinquent Enrollee in a Non-group Health Plan has not paid outstanding Premiums in full by the due date indicated in the notice of delinquency, then the coverage is terminated retroactively to the last day of the last month for which the Enrollee has paid for coverage in full. The Connector shall notify the Enrollee of the termination. (4) Delinquent Enrollee Premiums for Non-group Health Plans with Financial Assistance. An Enrollee in a Health Plan with APTC Only or in ConnectorCare who fails to pay a monthly Premium in full by the payment due date will be considered delinquent and will be notified when the account is past due. If an Enrollee's account is delinquent for two consecutive months, the Enrollee will be notified by a notice of delinquency which will inform the Enrollee that, if payment of all outstanding Premium is not received in full on or before the payment due date indicated in the notice, then the coverage will be terminated retroactively to the last day of the first coverage month in which the Enrollee was delinquent. (5) Termination from a Non-group Health Plan with Financial Assistance for Failure to Pay Enrollee Premiums. If an Enrollee who is delinquent fails to pay all Premiums owed in full by the due date after receiving the second notice described in 956 CMR 12.12(4), then the coverage is terminated retroactively to the last day of the first coverage month in which the Enrollee was delinquent. The Enrollee will be notified of the termination with a notice of termination. (6) Reinstating Coverage in a Non-Group Health Plan Following Termination for Failure to Pay Premiums. An Enrollee in a Non-Group Health Plan who was terminated for non-payment of Premium and who makes a timely request to reinstate coverage may do so, provided that all outstanding Premiums for such terminated Enrollee have been paid in full, as well as the next month’s Premium, by the deadline determined by the Connector. (7) Waiver or Reduction of Premium for Extreme Financial Hardship. (a) Extreme financial hardship means that the individual has shown to the satisfaction of the Connector that the individual: 1. Is homeless, or is more than 30 days in arrears in rent or mortgage payments, or has received an eviction or foreclosure notice within the last 60 days; or 2. Has a shut-off notice, or has been shut off, or has a refusal to deliver essential utilities within the 60 days prior to application (gas, electric, oil, water, or sole telephone); or 3. Has incurred a significant, unexpected increase in essential expenses within the last six months resulting directly from the consequences of: a. Domestic violence; b. The death of a spouse, family member, or partner with primary responsibility for child care; c. The sudden need to provide full-time care for self, for an aging parent or for another family member, including a major, extended illness of a child that requires a working parent to hire a full-time caretaker for the child; or d. A fire, flood, natural disaster, or other unexpected natural or human-caused event causing substantial household or personal damage for the individual; or 4. Has filed for bankruptcy within the last 12 months as long as the debts have not yet been discharged. (b) If the Connector determines that the requirement to pay a Premium or arrears would result in extreme financial hardship for an individual, the Connector may waive payment of such Premium or arrears; or reduce the amount of such Premium or arrears assessed to the individual. The Connector will assume payment to the Health Carrier of the amount of the individual's Premium that is waived or reduced during the waiver period. The Connector will waive or reduce only the portion of Premium that equals the minimum Premium for the individual's ConnectorCare Plan Type. (c) An Applicant who has been found eligible for ConnectorCare may request a premium waiver prior to enrollment, although the filing of such request does not entitle such Applicant to enroll at a reduced Premium or without paying the Premium while the request is pending. Further, where any Applicant is approved for a reduced Premium, but must continue to pay a portion of Premium because the Applicant was not approved for a full waiver of Premium, the Applicant has not chosen to enroll in the lowest-cost ConnectorCare Plan, or the Applicant has not chosen to apply all APTC toward the Applicant's ConnectorCare Plan, such Applicant shall not be enrolled, unless the Applicant pays the remaining portion of Premium by the deadline established by the Connector. (d) Waivers or reduction of premium may be authorized for up to 12 months. Waivers or reduction of premium may be retroactive, including where an Enrollee has become delinquent in accordance with 956 CMR 12.12(4) and is seeking to reduce Premium for the period of delinquency, or where an Enrollee has been terminated in accordance with 956 CMR 12.12(5), is seeking to reinstate coverage in accordance with 956 CMR 12.12(6), and is seeking to reduce Premium for the period of reinstated coverage. An individual who is granted a waiver or reduction will be allowed to enroll in a Health Plan, as made available to that individual through the Health Connector. At the end of the waiver or reduction period, the individual may submit another request if the extreme financial hardship persists. (e) Enrollees who have been approved for a waiver or reduction of premium or whose waiver or reduction period has ended may transfer to a different Health Plan within 60 days. (f) Premiums for Non-group Health Plans with APTC only or Non-group Health Plans without Financial Assistance shall not be eligible for a waiver or reduction of Premium for extreme financial hardship. (8) Change in Premium for Non-group Health Plans. (a) Premiums for individuals enrolled in Non-group Health Plans may change based on changes in Household composition, eligibility, or Enrollee address, and such Premium changes will follow the eligibility effective date provisions found at 956 CMR 12.08. (b) Premiums for individuals enrolled in Non-group Health Plans may change from year to year. (9) Minimum Monthly ConnectorCare Premium Schedule. The Board shall determine annually the minimum monthly Premium for each Plan Type. The Premiums shall be set forth in a schedule that will be published annually. (10) Monthly ConnectorCare Premium Assistance Payments. The Connector will make Premium Assistance payments to Health Carriers for Health Plans on behalf of ConnectorCare Enrollees monthly, using funds appropriated bythe Commonwealth for the purpose, or otherwise made available to the Connector. (11) Delinquent Small Employer Premiums for Small Group Health Plans. A Small Employer that fails to pay its monthly Premiums in full by the payment due date will be considered delinquent and will be notified when its account is past due. This notice of delinquency will inform the Small Employer that, if payment of all outstanding monthly Premium is not received in full on or before the payment due date indicated in the notice, then the coverage will be terminated retroactively to the last day of the last month for which the Small Employer has paid for coverage in full. (12) Termination from a Small Group Health Plan for Failure to Pay Premiums. If a delinquent Small Employer has not paid its outstanding Premiums in full by the due date indicated in the notice of delinquency, then the coverage is terminated retroactively to the last day of the last month for which the Small Employer has paid for coverage in full. The Small Employer and any Enrolled Employees will be notified of the termination with a notice of termination. (13) Reinstating Coverage in a Small Group Health Plan following Termination for Failure to Pay Premiums. A Small Employer that was terminated for non-payment of Premiums may reinstate coverage within 30 days from the date coverage was terminated. All outstanding monthly Premium must be paid in full as well as the Premium for the following month of coverage.