13. What happens to a ConnectorCare application if eligibility factors are not verified electronically?
If self-declared information cannot be electronically verified, the HIX will make a temporary ConnectorCare eligibility determination based on the self-declared information. In Massachusetts, this is called “provisional eligibility,” in the federal regulations it is referred to as the “inconsistency period.” The applicant will be asked to submit required proof within 90 days to remain eligible but in the meantime will be able to enroll in a plan based on the self-attested information. However, provisional eligibility does not apply if the data shows the person is dead or already enrolled in Medicare or MassHealth.
The Connector may extend the 90 day provisional eligibility period on request if the applicant has been making a good faith effort to obtain the required proof. 45 CFR 155.315(f)(3). On a case by case basis, the Connector may also accept self-attestation and an explanation of why proof is not reasonably available as sufficient verification except with respect to proof of US citizenship or an eligible immigration status. 45 CFR 155.315(g).
When proof is submitted on or before the deadline, the HIX will make a new determination based on the proof. If the Connector receives no proof by the deadline, and the data source has information, HIX will make a new decision based on the data source. If the data source does not have information, HIX will issue a notice that, depending on the missing factor, will deny eligibility to purchase a QHP (based on lack of residence, citizenship/lawful presence, or incarceration) or allow purchase of a QHP but deny eligibility for a premium tax credit and ConnectorCare (based on excess income, tax filing factors, or minimum essential coverage).
An individual can supply the missing information after the 90 day deadline, but may no longer be within open enrollment. Enrolling outside of open enrollment requires a special enrollment period. If the delay in enrollment was based on an error on the part of MassHealth or the Health Connector, such as a delay in processing verification that was submitted on time, the Health Connector may approve a special enrollment period and a request for retroactive enrollment. 45 CFR 155.420 (d)(13) and (b)(2)(iii).
Differences between MassHealth and Connector Provisional Eligibility. MassHealth also has provisional eligibility but it can only be used once in a 12month period, and does not extend to unverified income for most adult applicants. These differences in provisional eligibility policies between MassHealth and the Health Connector may create a delay in coverage for applicants who attest to income under the MassHealth upper income limits but who in fact have income too high for MassHealth but within ConnectorCare upper income limits. Such applicants will receive neither MassHealth nor ConnectorCare until submitting proof of income. If the proof shows they are eligible for MassHealth, its coverage is retroactive, but if the proof shows higher income making them eligible for ConnectorCare, ConnectorCare will not ordinarily be retroactive, but see the Advocacy Tip above. Once enrolled in ConnectorCare, members who report an unverified decrease in income that would make them eligible for MassHealth may remain in ConnectorCare until they are found eligible for MassHealth based on verified income, unless they attest to income below the 100% FPL minimum income level and do not fall under the immigrant exception.