There are two different paths for resolving disputes in ConnectorCare depending on whether the adverse decision was made by the Health Connector, or the ConnectorCare plan.
If the dispute is with an action or failure to act by the Health Connector, in most cases, the first step will be to attempt to resolve a dispute informally through the customer service office. When customer service is unable to satisfactorily resolve a dispute, it can be “escalated” to the Health Connector Ombudsman. Certain disputes with the Health Connector can also be appealed to the Health Connector Appeals Unit. Individuals must be careful not to let appeal deadlines expire while trying to resolve a case informally.
If the dispute is with an action of the managed care plan, the first step will similarly be to attempt to resolve the matter with the plan’s customer service office. However, the plans all have formal procedures for resolving disputes internally and an enrollee must pursue the plan’s internal appeal process before he or she can appeal to the Office of Patient Protection.
In addition, individuals who are disputing the decision finding them eligible for ConnectorCare instead of MassHealth or finding them ineligible for either program may file appeals from the decisions of both agencies. Each agency is required to coordinate appeals by transmitting information to the other agency in order to minimize the burden on the appellant. 45 CFR 155.510
Appealing decisions made by the Connector. Applicants and enrollees have a right to a hearing to appeal from the following decisions by the Connector:
- Any adverse decision concerning any ConnectorCare eligibility factor, (see Q & A above Who is eligible for ConnectorCare?)
- Any decision concerning the amount of any premiums due or assignment to a Plan Type
- The Connector’s denial of a premium waiver or reduction based on financial hardship
- The Connector’s denial of a special enrollment period to enroll in a plan or change plans outside of the open enrollment period
- The Connector’s failure to give timely notice of decision
956 CMR 12.12 and 45 CFR 155.505 (b)(Right to appeal)
Appealing decisions made by a ConnectorCare plan. Most disputes about access to and payment for a particular medical service should be raised in the first instance with the ConnectorCare HMO. Each HMO has a grievance/appeal process for resolving such disputes that is described in the member handbook. If a dispute about the medical necessity of a covered service cannot be resolved with the HMO, an enrollee is entitled to an external appeal. In some cases it may also be helpful to bring such a dispute to the attention of the Connector legal office if it appears that a plan’s actions may be in violation of its contractual obligations to the Connector.
ConnectorCare plans are subject to state insurance regulation and enrollees are entitled to the consumer protections of the state managed care law. After an individual has exhausted the plan’s internal appeal process, there is a further appeal to the Office of Patient Protections (OPP) under the state managed care law. Since 2013, the OPP has operated under the Health Policy Commission. The OPP can resolve disputes over whether a service is medically necessary including whether the service requires an out of network provider. In most cases ongoing treatment can be continued pending appeal. There is also a consumer complaint process with the Department of Insurance.
G.L. c. 176O (Health Insurance Consumer Protections); 211 CMR 52, Division of Insurance, Managed Care Consumer Protections; 958 CMR 3.0, Health Policy Commission, Health Insurance Consumer Protections (includes requirements for carriers’ internal grievance procedures and the requirements for external reviews of carriers’ medical necessity adverse determinations), and Office of Patient Protection sub-regulatory guidance, bulletins and memos available at https://www.mass.gov/service-details/hpc-regulations-and-guidance.