In MassHealth, eligibility and coverage are concurrent, but that is not true in the Health Connector. Once found eligible for ConnectorCare, an applicant must take further action to affirmatively enroll by certain deadlines before coverage can begin. Enrollment can only occur during an annual open enrollment period or after a qualifying event that occurs outside open enrollment and creates a special enrollment period as discussed in the next three Q & As.

In general, enrollment is prospective after selecting a plan and paying any premium due. At initial enrollment, plan selection and payment of the first month’s premium must be completed by the end of the day on the 23rd of the month in order for coverage to begin on the 1st of the following month. The applicant can also select a date on the first of a later month within the enrollment period, however, an individual who misses the deadline for the initial month he or she selected will have to “shop” again and affirmatively select coverage for a later month within the enrollment period.

Advocacy Reminder:

There are limited opportunities for retroactive enrollment in ConnectorCare. Retroactive enrollment will always require a special request to Customer Service or an appeal. After certain kinds of special enrollment periods including those based on errors, or misrepresentation by the Health Connector or its agents, contract violations, “special circumstances” identified by the Connector or in some failure to verify situations, the effective date of coverage may be an “appropriate date based on the circumstances of the special enrollment period.” 45 CFR 155.420(b)(2)(iii) [1]. As discussed below in a later Q & A, a hearing officer can also set a retroactive effective date after a successful appeal.

• In training for enrollment assisters in the summer of 2018, the Connector described a policy for retroactive enrollment based on an error by the Health Connector, a member’s hospitalization, a death in the family or other exceptional circumstances that prevented an individual from selecting a plan and paying the premium. The process requires the applicant to request retroactive enrollment from a Health Connector Customer Service representative and pay all monthly premiums for the requested months as well as the next month’s premium. The process may take 10-15 business days to complete and some requests may require health plan approval.

45 CFR 155.420(b) [1](Effective dates). Health Connector Policy, NG-3, Enrollment in Individual and Family Plans [2], Jan. 1, 2015.

Open enrollment is an annual period in which individuals can enroll in or change their coverage for the year beginning January 1. The federal government selects the open enrollment period for the federal Marketplace, but state-based Marketplaces like the Health Connector can select a different enrollment period. In 2019, open enrollment in Massachusetts was Nov.1, 2018 to Jan. 23, 2019 for 2019 coverage. 

Enrolling outside of open enrollment or changing plans once enrolled is only allowed after a “qualifying event” creates a “special enrollment period” (SEP) during which an individual may enroll or change plans. Generally the SEP is 60 days from the qualifying event. Being found newly eligible for ConnectorCare automatically triggers a special enrollment period. 

Federal law requires certain qualifying events but state-based Marketplaces like the Health Connector can also define additional qualifying events. An individual applying online or by telephone will be asked about the existence of a qualifying event if that is needed to enroll. An individual applying by paper who needs a qualifying event to enroll will receive a notice with information about how to request a special enrollment period  along with the eligibility determination.

Being found newly eligible for ConnectorCare automatically triggers a special enrollment period without an applicant having to ask for it. This is by far the most important qualifying event added by the Health Connector. 

For all other qualifying events, the applicant must request an SEP, and the Health Connector must agree that an SEP applies before an individual can enroll. An individual may also be asked to supply proof of the qualifying event within 90 days. If proof is not supplied, the individual will be terminated from coverage. Within 35 days of the termination notice, the individual can request reinstatement in the same plan provided he or she submits the proof and pays the premium for the balance owed and the next month. If the Health Connector denies a request for an SEP, it issues a written decision that is subject to appeal.

Qualifying events defined in federal law, 45 CFR 155.420 [1]

• A change in household because of: 
  • Marriage  
  • Birth
  • Adoption or placement for adoption 
  • Death, divorce or legal separation from spouse
• A loss of health insurance because of: 
  • Loss of job or reduced hours 
  • Change in job or move outside service area of current plan 
  • Change in eligibility for employer plan or significant change in plan options 
  • Change in employer plan or employee’s FPL such that employer plan no longer affordable or minimum value 
  • No longer MassHealth eligible o Loss of coverage on parent’s plan on turning 26 
  • Health plan no longer QHP 
  • Expiration of COBRA 
  • No longer student health plan eligible

NOTE: Loss of coverage based on failure to pay premiums or voluntarily terminating coverage is not a qualifying event.

• Changes making an individual newly eligible  
  • A change in status as US citizen or lawfully present immigrant
  • A change in FPL that makes an unsubsidized QHP enrollee or dependent newly eligible for PTC or ineligible for PTC 
  • Release from incarceration  
  • Permanent move to Massachusetts from prior place of residence 
• Victims of domestic abuse or spousal abandonment and dependents who are enrolled in coverage with the abuser or the abandoning spouse and seek to obtain separate coverage
• An applicant who is assessed as potentially eligible for MassHealth and is determined ineligible for MassHealth after open enrollment has ended or initial SEP expired.
• Individuals who gain or maintain status as an Indian and their dependents; they may enroll or change QHP one time per month
• Special circumstances affecting enrollment include: 
  • Enrollment or failure to enroll due to error, misrepresentation or inaction by the Health Connector, certified application counselors or Navigators  
  • The individual demonstrates that material error influenced decision to enroll or not enroll 
  • Misconduct by a Navigator, broker or certified application counselor 
  • The ConnectorCare plan/QHP significantly violated its contract with the consumer 
  • At the option of  the Health Connector, the individual provides satisfactory evidence to verify eligibility after termination due to failure to verify within the required period 
  • The consumer experienced other exceptional circumstances preventing enrollment as the Connector may provide, this currently includes hospitalization or a death in the family

Additional qualifying events in ConnectorCare regulations, 956 CMR 12.10(5)(b)-(e) [3]

• Being determined newly eligible for ConnectorCare 
  • Applicants do not have to identify this qualifying event or request an SEP, HIX will recognize when an applicant is newly eligible for ConnectorCare. However this qualifying event will not help an individual who was previously found eligible for ConnectorCare and did not enroll by the deadline. He or she will have to wait until open enrollment unless another qualifying event applies.
• A change to a different one of the three Plan Types for an existing enrollee.
• Approval of a premium hardship waiver. 
• The expiration of a hardship waiver. 

Individuals generally have 60 days to enroll or change plans from the date of one of these triggering events. 

Additional qualifying events in state law: OPP waiver, 958 CMR 4.00 [4]

• If the Health Connector denies enrollment because someone does not have a qualifying life event and open enrollment has ended, the denied applicant can request a waiver from the Office of Patient Protections (OPP), an office of the Health Policy Commission. 
• The waiver request must be filed within 30 days of the denial notice and include a copy of the denial. The waiver form asks the applicant to explain why they did not enroll during open enrollment or after losing coverage and the applicant must certify that he or she did not intentionally forego coverage. If a waiver is granted, the individual may return to the Connector and complete enrollment. 

See also, Health Connector Policy, NG-1E, Mid-Year Life Events or Qualifying events [5], rev. Jan. 27, 2016

Most SEPs consist of a 60 day period in which an individual can enroll prospectively by selecting a plan and paying the premium by the 23rd of the month for coverage to begin in the following month. However, certain SEPs may allow for a retroactive effective date.

Advocacy Reminder:

The SEP for the birth or adoption of a child provides for retroactive enrollment in a QHP to the date of birth or adoption. However, a child born to a mother enrolled in ConnectorCare will ordinarily be eligible for MassHealth. If the mother is not on MassHealth, newborn coverage is only retroactive for 10 days from application.  The birth to a mother who is not herself enrolled in MassHealth should be reported within 10 days of birth to assure that if the child is eligible for MassHealth, enrollment will go back to the date of birth. 

Certain other SEPs allow for a special effective date of coverage based on the circumstances of the SEP and may also be retroactive. They include: enrollment or non-enrollment due to error by the Connector, its agents, or by enrollment assisters, the plan’s material violation of its contract, a MassHealth determination of ineligibility that does not occur until after Connector enrollment periods have expired, other material error, other exceptional circumstances such as hospitalization or a death in the family or, at the option of the Connector, satisfactory verification of eligibility following denial for failure to verify.  45 CFR 155.420(b)(2)(iii) [1]. As a practical matter the effective date in these situations is usually worked out through a 3-way negotiation among the applicant/enrollee, Health Connector staff and the health plan. The denial of an SEP is appealable as discussed in a later Q & A.

45 CFR 155.420(b) [1]; 956 CMR 12.10 [3]

The Health Safety Net. The Health Safety Net (HSN) is available to state residents with income that does not exceed 300% FPL using the MassHealth MAGI and income verification rules. Acute care hospitals and community health centers bill HSN for services to HSN-eligible individuals who are uninsured or underinsured. However, if HSN-eligible individuals are also found eligible for ConnectorCare, it will limit their HSN eligibility period. Such individuals will be eligible for HSN from the “medical coverage date” (10 days prior to the date of application for those under 65) and for up to 90 days after the date they are found eligible for HSN. See, MassHealth Eligibility Operations Memo 18-02 [6] (July 1, 2018). After that time elapses, or they enroll in ConnectorCare, whichever comes first, they will retain HSN only for adult dental services not covered in ConnectorCare. An individual who fails to enroll in ConnectorCare when eligible to do so will later lose all HSN benefits except for dental.  

MassHealth Limited. MassHealth Limited only covers emergency services and doesn’t count as government sponsored MEC. Certain lawfully present noncitizens may be eligible for both MassHealth Limited and ConnectorCare at the same time. These individuals will be non-citizens whose MassHealth MAGI income is at or under 133% FPL and who are lawfully present for purposes of the Health Connector but do not meet MassHealth immigrant eligibility rules for MassHealth Standard or CarePlus. 

Advocacy Reminder:

When individuals are found eligible for ConnectorCare and Limited and receive an approval notice from MassHealth and a MassHealth card, they may easily be confused about their coverage. They may not understand that Limited covers only emergencies, and fail to take further action to enroll in ConnectorCare during open enrollment. Language issues may contribute to the confusion. In such situations, it may be possible to obtain a special enrollment period or a waiver from the Office of Patient Protections to enable the individual to enroll in ConnectorCare.

Despite the confusion, there are some advantages to being found eligible for ConnectorCare and Limited: An infant born to a mother eligible for Limited will be automatically enrolled in MassHealth Standard effective on the date of birth; Limited eligibility will be retroactive 10 days prior to the date of application for those under 65 or up to 3 months retroactive from the month of application for those 65 or older, and, for those who do not enroll in ConnectorCare, Limited will be available to cover emergency services even after full Health Safety Net coverage has expired.

101 CMR 613.04(6)(a)(2) [7] (HSN primary and secondary) and (7) (HSN eligibility period) and 613.02 [7](definition of medical coverage date); MassHealth Eligibility Operations Memo 18-02 [8] (July 1, 2018). 130 CMR 506.006 [9] and 519.009 [10] (Limited eligibility), 450.105(F) [11] (Limited coverage) and 505.002(B)(1)(b) [12] (Newborns).