Amendment #3 to H.3452

Expand Open Enrollment Exemption Criteria

Ms. Balser of Newton move that the bill be amended by striking out section 49 and inserting in place thereof the following section:



SECTION 49. Subsection (a) of section 4 of said chapter 176J, as so appearing, is hereby amended by striking out clause (2), and inserting in place thereof the following clause:-

(2) A carrier shall enroll eligible individuals, as defined by section 1, and eligible individuals, as defined in section 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. 300gg-41(b), into a health plan if those individuals request coverage within 63 days of termination of any prior creditable coverage or within 63 days of experiencing a qualifying event. A carrier shall enroll persons eligible to buy child-only plans into a health plan if coverage is sought for the eligible individual within 180 days of a qualifying event. Qualifying events shall include, but not be limited to, the following:

(i) the individual was dis-enrolled from individual creditable coverage due to loss of status as a dependent on another individual’s health plan;

(ii) the individual was dis-enrolled from individual creditable coverage due to the carrier’s termination of the plan;

(iii) the individual had creditable coverage in an individual health plan with coverage available only in a limited service area and this coverage is terminated because the individual has moved to a location in Massachusetts that is outside the original plan’s service area;

(iv) the individual loses eligibility for a qualified student health insurance plan;

(v) the individual cancels mini-COBRA or COBRA coverage;

(vi) the individual has a change in eligibility for cost-sharing reductions or for advanced payments of the premium tax credit pursuant to the Affordable Care Act;

(vii) the individual was denied eligibility for a subsidized health insurance plan, including MassHealth, Commonwealth Care, Medical Security Program or other similar programs;

(viii) for an individual eligible to buy a child-only plan, the birth or adoption of the eligible individual child shall be considered a qualifying event;

(ix) the individual meets other exceptional circumstances as the commissioner may provide; or

(x) any other event as may be designated by the commissioner.

A carrier shall enroll an eligible dependent, as defined by section 1, into a health plan if coverage is sought for the eligible dependent within 63 days of a qualifying event. A carrier shall enroll the eligible dependent under age 19 of an eligible individual into a health plan if coverage is sought for the eligible dependent within 180 days of a qualifying event. Qualifying events for an eligible dependent shall include, but not be limited to, the following:

(i) marriage or establishment of domestic partnership, if available under the terms of the policy;

(ii) birth of a child;

(iii) adoption of a child or placement of that child for adoption;

(iv) the dependent’s loss of creditable coverage from another group or government plan;

(v) upon court order;

(vi) the individual has a change in eligibility for cost-sharing reductions or for advanced payments of the premium tax credit;

(vii) the dependent was denied eligibility for a subsidized health insurance plan;

(viii) the dependent meets other exceptional circumstances as the commissioner may provide; or

(ix) any other event as may be designated by the commissioner.

A carrier shall also enroll eligible individuals, as permitted under the federal Patient Protection and Affordable Care Act, and any rules, regulations and guidances applicable thereto, as amended from time to time. A carrier shall enable any such eligible individual to renew coverage if that coverage is available to other eligible individuals. Coverage shall become effective in accordance with the federal Patient Protection and Affordable Care Act, and any rules, regulations and guidances applicable thereto, as amended from time to time, subject to reasonable verification of eligibility, and shall be effective through December 31 of that same year. Carriers shall notify any such eligible individuals that:

(i) coverage shall be in effect only through December 31 of the year of enrollment;

(ii) if any such eligible individual is in a health plan with a plan-year deductible or out-of-pocket maximum, then an explanation of how that deductible or out-of-pocket maximum and premiums will be impacted for the period between the plan effective date and December 31 of the enrollment year; and

(iii) the next open enrollment period during which any such eligible individual shall have the opportunity to enroll in a health plan that will begin on January 1 of the following calendar year.

A carrier shall not impose a pre-existing condition exclusion or waiting period of any duration on a health plan.