Appeal Process

(1) Appeal requests will be processed and hearings will be conducted by the Connector using the policies and procedures for informal hearings set forth in 801 CMR 1.02: Informal/Fair Hearing Rules, as well as the procedures set forth in 956 CMR 12.00 or in any administrative bulletins issued by the Connector. In addition, regarding appeals of Connector Programs related to Non-group Health Plans, the Connector will use the policies and procedures at 45 CFR 155.500 through 155.550, and regarding appeals of Health Connector Programs related to Small Group Health Plans, the Connector will use the policies and procedures at 45 CFR 155.741. (2) The Connector may dismiss any appeal request if: (a) It is not received within the time periods specified in 956 CMR 12.14; (b) It does not state a valid ground for appeal under 956 CMR 12.13; (c) The appeal is withdrawn by the appellant or Appeal Representative; (d) The appellant dies while the appeal is pending, except if the executor, administrator, or other duly authorized representative of the estate requests to continue the appeal; or (e) For any reason stated in 801 CMR 1.02: Informal/Fair Hearing Rules. (3) The Connector may designate a hearing officer to hear any appeals. The hearing officer may, at the request of a party or on his or her own initiative, order that the hearing be conducted by telephone. (4) Basis of Hearing Decisions. (a) The hearing officer's decision is based upon evidence, testimony, materials, and legal rules presented at the Hearing, as well as the Connector's rules, policies, and regulations, of which the hearing officer may take administrative notice. (b) The decision shall be based upon a preponderance of evidence. (c) The decision must be rendered in accordance with the law. 1. The law includes the state and federal constitutions, statutes, and duly promulgated regulations, as well as decisions of the state and federal courts. 2. Notwithstanding 956 CMR 12.15(4)(c)1, the hearing officer shall not render a decision regarding the legality of federal or state law including, but not limited to, Connector regulations. If the legality of such law or regulations is raised by the appellant or is otherwise the subject of consideration when rendering a hearing decision, the hearing officer shall render a decision based on the applicable law or regulation as interpreted by the Connector and as reflected in Connector Rules and Regulations, or other written guidance of the Health Connector. (5) The decision of the hearing officer designated by the Connector will be final, except that within 14 days of the issuance of the hearing officer's decision, the Director of the Appeals Unit for the Connector, or the Director's designee, may, for good cause, and at the request of the appealing party or on his or her own initiative, order a rehearing before another hearing officer. In the event that the Director or the Director's designee orders a rehearing, the Director will give notice in writing to all parties of the date, time, and location of the rehearing. The rehearing will be conducted before another hearing officer whom the Director designates. Within 30 days after the order requiring rehearing, the designated hearing officer will conduct the rehearing and will either issue a superseding decision or decide not to issue a superseding decision. A request for rehearing stays the initial decision of the hearing officer, and that initial decision will not be deemed final for purposes of the filing of an action for judicial review under M.G.L. c. 30A, § 14, until the Director or the Director's designee issues a superseding decision or decides not to supersede the initial decision. (6) Enrollees who have brought an appeal must continue to pay all required Premiums during the pendency of the appeal. Persons who are appealing a denial of a premium waiver or reduction application must pay any applicable Premiums while the appeal is pending.