What does “open enrollment” mean?
Under Massachusetts law there are only certain times during the year when individuals and families who do not have access to employer-sponsored health insurance may apply for nongroup coverage. The time when individuals and families can apply – the time when health insurers open plans to new members – is called “open enrollment.” This is similar to the process employers use to allow their employees to sign up or change plans during specified times only.
Why doesn’t the law allow people to sign up at any time?
Although everyone in Massachusetts has been required to have health insurance for several years, some individuals waited until they needed expensive health care to purchase insurance and then dropped the coverage after the treatment ended, a practice that contributed to health insurance rate increases. The legislature created open enrollment to address this problem.
When is open enrollment?
This Division of Insurance bulletin lists the open enrollment dates. Open enrollment dates for 2013-2014 are:July 1, 2013 through August 15, 2013
October 1, 2013 through March 31, 2014
October 15, 2014 through December 7, 2014
I am self-employed and want to buy my own health insurance. Do I have to wait for open enrollment?
No. The law considers a self-employed person to be a small employer group (even if it’s only a “group” of one person) and the open enrollment rules do not apply to small group health insurance. An insurance carrier or agent may ask for documentation to prove that you are self-employed.
Visit www.mahealthconnector.org for information about Business Express.
Does this law apply to MassHealth?
No. If you qualify for MassHealth (Medicaid) or Commonwealth Care (state-subsidized health insurance) you can enroll throughout the year.
How would I know if I’m eligible for MassHealth or other government assistance?
You can call MassHealth or health Care for All at 1-800-272-4232 for help.
What if I have unpaid medical bills or my doctor told me that I need medical care right away? Who can help me figure out what to do?
You can call Health Care for All at 1-800-272-4232 for help.
Who can I call to help me understand these rules about buying health insurance?
For help understanding the law, call the Massachusetts Division of Insurance at 617‑521-7794. For help in understanding your options for coverage or if you need help filling out applications call Health Care for All at 1‑800‑272‑4232. For information about Commonwealth Care (the state-subsidized health insurance coverage), nongroup and small group plans and help enrolling in any of these plans, call the Commonwealth Health Insurance Connector at 1‑877‑623-6765.
Where can I go if I need help in another language?
You can call the Office of Patient Protection at 800-436-7757.
I tried to enroll in a nongroup plan but was told that I cannot apply because I am eligible for coverage through an employer. Is that true?
Yes, the law says that an eligible individual is someone who is not trying to replace employer-sponsored group coverage that meets Massachusetts requirements for minimum coverage.
Is there an exception? I was told I could get a waiver so I don’t have to take the coverage through work.
No. There is no waiver process for eligibility. If you have questions about the law that controls whether you are eligible to apply for nongroup insurance you should call the Division of Insurance at 617‑521‑7794.
But what if I don’t like the plan my employer offers, or it’s too expensive, or I missed the enrollment period at work?
Unfortunately the law does not allow for exceptions to this provision – if you are eligible for an employment-based plan, you are not eligible to purchase nongroup insurance.
What if my employer doesn’t offer insurance, but my spouse’s does? Do I have to take that plan or can I buy insurance on my own?
If your spouse’s employer offers the option of family coverage, then you are eligible for employer-sponsored coverage and the law does not allow you to purchase nongroup insurance.
If I am losing my current health insurance coverage, do I have to wait until open enrollment?
Most likely not, as the law provides exceptions for persons who experience a “qualifying event.” In general, if you apply within 63 days of losing prior coverage, you will be able to enroll. For more information about qualifying events, please call the Division of Insurance at 617-521-7794.
If I am eligible for nongroup insurance and it’s not open enrollment, is there an exception for people who missed open enrollment?
The law does provide for a waiver process for individuals who were unable to buy health insurance during open enrollment or when they were eligible following a qualifying event.
Who can apply for a waiver?
Eligible individuals, that is, those persons who are residents of Massachusetts and are not eligible for insurance through work, and who could not apply during open enrollment or when they were eligible following a qualifying event, can apply for a waiver. Persons who have access to employer-sponsored coverage and non-residents of Massachusetts are not eligible for nongroup coverage and are not eligible to apply for a waiver.
Where can I get a waiver form?
First you must apply for insurance, either directly with a health plan, through one of its agents, or through the Commonwealth Health Insurance Connector. If you are eligible to apply for a waiver, the health plan/agent will give you the waiver form along with the letter denying you enrollment. You can also find the waiver form on the Office of Patient Protection website (www.mass.gov/hpc/opp).
Should I apply for a waiver before I apply for health insurance?
No. The first step is to apply for health insurance, because you may be eligible to enroll without a waiver or you may not be eligible at all. The health plan or its agent will make the determination and let you know.
Where can I get help to fill out the waiver form?
Please review the information on the Office of Patient Protection website. You can contact OPP at 800-436-7757 or HPC-OPP@state.ma.us for help.
Once I fill out the form, will I automatically get the waiver?
No. The Office of Patient Protection can only grant a waiver to someone who did not willfully forgo coverage.
What does “willfully forgo coverage” mean?
This means that you did not turn down the opportunity or fail to sign up for health insurance, for any reason, when you had the chance. It also means that you did not cancel coverage, including not paying your premium.
What does the Office of Patient Protection consider when reviewing a waiver request?
The Office of Patient Protection looks at the circumstances that prevented you from buying health insurance when you were eligible to buy it or during previous open enrollment periods.
Will I get a waiver if I can prove that I need medical care?
No. The Office of Patient Protection is not permitted to take into account anyone’s health conditions when reviewing a waiver request.
Once I fill out the form, how long will it take to hear?
The Office of Patient Protection is required to respond to you within 30 days. If the Office of Patient Protection asks you for any additional information, be sure to send it back as quickly as possible.
Can I request a hearing?
No, the Office of Patient Protection does not have hearing officers or conduct hearings. The Office of Patient Protection reviews the information that you submit and makes a determination based on what you submit, so be sure to provide all of the information that you think is important.
Can I come in and meet with someone at the Office of Patient Protection?
No, the Office of Patient Protection cannot accommodate walk-in visitors.
What happens if my waiver is denied?
You will have to wait until open enrollment to buy nongroup insurance.
I currently have nongroup coverage but cannot afford the latest rate increase. Can I get a waiver to change plans now?
No, if you are currently enrolled in a nongroup health plan, you must wait until open enrollment to change plans.
How does COBRA affect my eligibility for nongroup coverage?
Continuation of health coverage through COBRA or mini-COBRA (the state’s version of COBRA for small employers) is not considered to be employer-sponsored health insurance. If you have recently left your job you are eligible to apply for nongroup health insurance even if you are offered continuation through COBRA or mini-COBRA. You can apply for nongroup insurance outside of open enrollment if:
- you apply for nongroup insurance within 63 days of losing your employer-sponsored coverage or
- you apply for nongroup insurance within 30 days of canceling your COBRA or mini-COBRA.
For more information about how COBRA and mini-COBRA affect your options under the law that governs enrolling in nongroup health insurance, please call the Division of Insurance at 617‑521-7794. For general information about your options for obtaining health insurance please call Health Care for All at 1-800-272‑4232.
I am new to Massachusetts and just found out that I am required to have health insurance. Can I get a waiver so I can enroll now and avoid the penalty?
If you are within the 63-day period of losing prior coverage you may not need a waiver. If you are not eligible for coverage through work you should first apply to a health plan or its agent for coverage. If you are told that you are not eligible to enroll outside of open enrollment, you can apply for a waiver. If you lived in Massachusetts during the most recent open enrollment period, or you do not apply for coverage promptly once you become a resident of Massachusetts, you may have to wait for the next open enrollment period to apply. Please be aware that when you apply for coverage, insurers may ask you for proof of residency.
I could not afford to purchase health insurance until now. Can I get a waiver so I can enroll now and avoid any additional penalty?
If you are not eligible for coverage through work, you can apply for a waiver, but please be aware that if you could have applied for coverage during the most recent open enrollment period or within 63 days of losing prior coverage and did not do so, for any reason, your request will not be approved and you will have to wait until the next open enrollment period.
What if I applied for an affordability waiver through the Connector and did not have to pay a penalty because the Connector agreed that I could not afford insurance?
You should submit evidence of your Connector waiver when you apply for your enrollment waiver and proof of when your financial status changed. Remember that if you could have applied for coverage during open enrollment and did not do so you will have to wait for the next open enrollment period to purchase insurance.
I was receiving unemployment benefits and had coverage through the Medical Security Plan. I no longer receive unemployment compensation so I will no longer have health coverage. Can I get a waiver so that I can buy nongroup insurance?
You should not need a waiver if you are applying within 63 days of losing your coverage with the Medical Security Plan. If you are within the 63 days and having trouble enrolling, you should call the Division of Insurance at 617‑521‑7794 for assistance.
I applied for MassHealth and/or Commonwealth Care during open enrollment and received my denial after open enrollment had closed. Can I apply for a waiver or do I have to wait until the next open enrollment period to apply for health insurance?
You should submit your denial notice from MassHealth/Commonwealth Care when you file your waiver request. You may be eligible to receive a waiver if you were actively applying for benefits during open enrollment and received a denial after open enrollment ended.
I cannot afford insurance. Should I apply for a waiver to the Office of Patient Protection so I don’t have to pay the penalty?
No. The waiver process for affordability, i.e., so that you don’t have to pay a penalty for not having insurance because you cannot afford insurance, is a different process. For more information about that process, please call the Commonwealth Health Insurance Connector at 1‑877‑623-6765 or visit www.mahealthconnector.org. Be sure to tell them that you are calling about an affordability waiver and not an enrollment waiver.
Who can I call if I have questions about enrollment?
- For questions about the law that governs open enrollment or eligibility, please call the Division of Insurance at 617-521-7794.
- For questions about access to health insurance, please call Health Care for All at 1-800-272‑4232.
- For questions about Commonwealth Care (the state-subsidized health insurance coverage), nongroup and small group plans and for help enrolling in any of these plans, call the Commonwealth Health Insurance Connector at 1‑877‑623-6765.
- For questions about the waiver process or the waiver form, please call the Office of Patient Protection at 1‑800-436-7757 or contact us at HPC-OPP@state.ma.us.
- For MassHealth/Medicaid please call 1-800-841-2900.
Last Updated April 2013