211 CMR 66.05 - Renewability

(1) Except as provided in 211 CMR 66.05(2), every Health Benefit Plan shall be renewable as required by the Health Insurance Portability and Accountability Act of 1996.

(2) A Carrier is not required to renew the Health Benefit Plan of an Eligible Small Business if the small business:

(a) has not paid the required premiums; or

(b) has committed fraud, misrepresented whether a person is an Eligible Employee, or misrepresented information necessary to determine the size of a group, the Participation Rate of a group, or the premium for a group; or

(c) failed to comply in a material manner with Health Benefit Plan provisions including Carrier requirements regarding employer contributions to group premiums; or

(d) fails, at the time of renewal, to satisfy the definition of an Eligible Small Business or meet the Participation Requirements of the Health Benefit Plan; or

(e) fails to comply with reasonable requests to verify the information described in 211 CMR 66.04(1)(g); or

(f) is not actively engaged in business.

(3) A Carrier is not required to renew the Health Benefit Plan of an Eligible Individual, Eligible Employee, or Eligible Dependent if said person:

(a) has not paid the required premiums;

(b) has committed fraud or misrepresented whether he or she qualifies as an Eligible Individual, Eligible Employee, Eligible Dependent, or misrepresented information necessary to determine his or her eligibility for a Health Benefit Plan or for specific health benefits;

(c) has failed to comply in a material way with the provisions of the Health Benefit Plan, the Member contract or the subscriber agreement including, but not limited to, relocation of the individual, employee, or dependent, outside the service area of the Carrier;

(d) fails, at the time of renewal, to satisfy the definition of an Eligible Individual, Eligible Employee, or Eligible Dependent, provided that the Carrier collects sufficient information to make such a determination and makes such information available to the Commissioner upon request; or

(e) has failed to comply with the Carrier's reasonable request for information in an application for coverage.

(4) A Carrier must file with the Commissioner any material changes in the criteria it uses under 211 CMR 66.05(2) and/or (3) to determine the nonrenewability of a Health Benefit Plan for an Eligible Small Business, Eligible Individual, Eligible Employee, or Eligible Dependent, as applicable, as part of the annual filing required by 211 CMR 66.12.

(5) A Carrier must provide at least 60 days prior notice to an Eligible Individual or Eligible Small Business of the Carrier's intention not to renew that Eligible Individual or Eligible Small Business's Health Benefit Plan and the specific reason(s) for the nonrenewal in accordance with the Carrier's filed criteria. A Carrier must provide at least 90 days prior notice to affected Eligible Individuals or Eligible Small Businesses of the Carrier's intention to discontinue offering a particular type of Health Benefit Plan.

(6) A Carrier that elects to nonrenew all of its Health Benefit Plans delivered or issued for delivery to Eligible Individuals and Eligible Small Businesses in Massachusetts:

(a) must submit to the Commissioner, 30 days in advance of providing notice required under 211 CMR 66.05(6)(c) a statement certified by an officer of the Carrier that specifies:

1. The date by which it will nonrenew all of its Health Benefit Plans to all groups;

2. The reason(s) for the nonrenewal of all Health Benefit Plans;

3. The number of groups and individuals covered by the nonrenewed Health Benefit Plans, both in Massachusetts and in its total book of business; and

4. An acknowledgment that the Carrier is prohibited from writing new business in the individual and small group market in Massachusetts for a period of five years from the date of notice to the Commissioner, unless the Commissioner has determined, in his or her discretion, that the Carrier is entitled to an exemption from the requirements of 211 CMR 66.05(6)(a)(4) pursuant to 211 CMR 66.05(6)(e).

(b) The Commissioner may disapprove, within 21 days of receiving notice under 211 CMR 66.05(6)(a), a Carrier's election to nonrenew if the Carrier fails to comply with 211 CMR 66.05(6)(a) or is in violation of 211 CMR 66.05(8).

(c) A Carrier must provide notice of the decision not to renew coverage to all affected Eligible Individuals or Eligible Small Businesses at least 180 days prior to the nonrenewal of any Health Benefit Plan by the Carrier in the event the Commissioner has not disapproved the Carrier's election to nonrenew;

(d) After the 180-day notification period, a Carrier must nonrenew coverage to Eligible Individuals or Eligible Small Businesses only on the date of renewal for each individual or small business. and

(e) A Carrier may request a waiver from the requirements of 211 CMR 66.05(6), if the Carrier is a member of an insurance holding company system or health maintenance organization holding company system as defined by M.G.L. c. 175, § 206 and M.G.L. c. 176G, § 1 and at least one Health Benefit Plan that is considered to be substantively similar, pursuant to M.G.L. c. 176J and 211 CMR 66.00, to the Health Benefit Plan(s) to be non-renewed by the Carrier will continue to be offered by an affiliate of the Carrier as defined by M.G.L. c. 175, § 206 and M.G.L. c. 176G, § 1. A waiver provided under 211 CMR 66.05(6)(e) will be at the Commissioner's discretion.

(7) Nothing in 211 CMR 66.05 prohibits a Carrier from canceling during the term of the policy a Health Benefit Plan issued to an Eligible Individual or Eligible Small Business for the reasons outlined in 211 CMR 66.05(2)(a) through (c) or (f) or (3)(a) through (c); provided that if the Carrier cancels the Health Benefit Plan for the reason found in 211 CMR 66.05(2)(a) or in 211 CMR 66.05(3)(a) during the policy term, a Carrier must provide the Eligible Individual or Eligible Small Business with any grace period as provided in the Eligible Individual's or Eligible Small Business's Health Benefit Plan, including any prior notification requirements.

(8) In no event may a Carrier deny an Eligible Individual or Eligible Small Group renewal of a Health Benefit Plan as part of an effort to circumvent the intent of M.G.L. c. 176J.

(9) In no event shall a Carrier deny an Eligible Individual renewal of a Health Benefit Plan, except as permitted in 211 CMR 66.05(3), provided, however, that any Eligible Individual whose policy was issued outside of the annual open enrollment described in 211 CMR 66.04(1) who seeks to renew that policy must renew during the next open enrollment period.

(10) If a Carrier re-verifies the eligibility of renewing individuals or small businesses, it shall complete the re-verification at least 90 days prior to renewal.

Notes

211 CMR 66.05

Amended by Mass Register Issue 1349, eff. 10/6/2017. Amended by Mass Register Issue 1487, eff. 1/20/2023.