The Commission shall determine whether any individual municipal subscriber qualifies for the Commission's insurance coverage pursuant to M.G.L. Chapter 32A, s.2. Under this regulation, "Authority" shall mean Appropriate Public Authority, as defined in M.G.L.c. 32B s 2. If the Commission approves a transfer of all of an Authority's insureds and dependents whom the Commission determines to be eligible to join the Commission's insurance coverage, it shall do so according to the conditions set forth in M.G.L. c.32B s.23.
(1) If an Authority chooses to transfer to the Commission, it shall provide a copy of the signed and executed agreement, or the order of the three-person panel, under M.G.L. c.32B s.21, to join the Commission's health coverage, along with a cover letter from an authorized official of the Authority that gives notice of a decision to transfer to the Commission. The said agreement or the order shall include the premium contribution details.
(2) An Authority that has given notice as defined in (1) above, of its decision to transfer shall provide the Commission with a completed "Required Municipal Initial Enrollment Data" of its current enrollee population for whom it provides health insurance coverage. These data shall be provided by the notice deadline for any given enrollment period and be in a format designated by the Commission. The Commission shall provide the file type, file layout, data elements and the Commission's Municipality Software Application upon request of the Authority. See the Required Municipal Initial Enrollment Data information for data details.
(a) Completeness of the aggregated data shall be assessed by use of the Commission's Municipality Software Application and shall be within a five percent error threshold.
(b) The total count of eligible subscribers, including all employees, retirees, and survivors who would be eligible for Commission health insurance whether or not currently enrolled shall be provided by the notice deadline.
(c) All Authorities shall provide the Commission with the following contact information: (i) IT contact and alternate, (ii) benefits coordinator and alternate, and (iii) authorized official and alternate. Contact information shall include mailing address, phone number and email address.
(d) All Authorities shall provide their benefits coordinator staff with internet access to utilize the Commission's eligibility system (known as the MAGIC system). The Commission shall provide authentication certificates, user IDs and passwords to allow access to the MAGIC system.
(3) The Authority shall provide, in advance, a draft to the Commission of the initial subscriber communication, which will be subject to the Commission's review. The Commission shall provide a template for this communication. Future communications regarding the Commission shall be cleared by the Commission in advance of their distribution. The Commission shall provide a master premium contribution chart for the Authority to use in developing a customized rate chart for its own contribution ratios as well as all benefit related materials. The Authority shall produce customized rate charts for its subscribers and shall provide them to the Commission in an ADA accessible format for the Commission's website.
(4) Authorities that do not meet the Commission's required deadlines during the implementation period may, at the Commission's sole discretion, have their coverage effective date delayed until the next scheduled enrollment period.
(5) The employees and retirees of a city, town, regional school district, charter school or any other statutorily authorized district shall not be eligible for Commission coverage unless they are members of a Massachusetts public sector retirement system, are receiving a pension from a public retirement system, or are survivors of members (OBRA is not such a public retirement system for this purpose).
(6) Upon the Authority's coverage effective date and for the duration of its coverage with the Commission, said Authority shall not provide any non-Commission health coverage to its employees except those subscribers for whom the Authority is obligated to provide health insurance coverage pursuant to M.G.L. c. 150E. Where an Authority has subscribers whose health insurance coverage is provided pursuant to a collective bargaining agreement and includes plan design features that are inconsistent with those of the Commission's coverage, then the Authority shall not transfer these subscribers to the Commission under M.G.L. c. 32B, s.23 until the end of the initial term of the agreement. With regard to the eligible subscribers still covered under collective bargaining agreements, where there are one or more differing end dates of their respective collective bargaining agreements, all such subscribers shall transfer to the Commission on July 1 st of any given fiscal year.
(7) Authorities transferring out of the Commission’s coverage pursuant to M.G.L. c.32B, s.23 shall provide the Commission with notice on or before October 1st for transfer on June 30th of the following year, and all of the Authority’s subscribers shall be transferred out on that date. The effective date for an Authority to withdraw from Commission coverage shall be on June 30th of the expiration year as specified in a municipal entity's bargained agreement or Order of the Panel.
(8) Health coverage for said Authorities' insureds shall begin on the effective date of transfer as determined by the Commission. The Commission's health coverage shall only apply to health care claims that are incurred on or after the effective date of transfer to the Commission. The Authority shall be solely responsible for continuing its insureds' health coverage until the effective date of transfer to the Commission, including coverage of any costs or claims incurred but not reported prior to the effective date of transfer.
(9) Prior to the effective date of transfer to the Commission's health coverage, the Authority shall distribute enrollment materials, as provided by the Commission, for health coverage enrollment to all prospective Insureds, including those who currently are not enrolled in the said Authority's health coverage. The Authority's Insureds shall be offered the same health plan choices offered to state Insureds who reside in the same geographic area.
(10) The Authority's insureds shall be eligible for the Commission's health coverage and shall be subject to the same health coverage terms, conditions, carriers, schedules, benefits and benefit levels as those provided to state Insureds. Changes in eligibility and effective dates will be determined by the Commission. Prior coverage through the Authority does not guarantee Commission coverage unless the Commission's eligibility requirements are met.
(11) Eligible Employees who apply for coverage within ten days of employment shall be insured either within 60 calendar days or two calendar months from said first day of employment, whichever is earlier. The first day of employment shall be counted when determining the effective date of Commission coverage, and one or more days of authorized leave of absence shall be counted as an equivalent number of days of employment.
(12) Coverage ends on the last day of the calendar month following the month that an employee leaves the service of his original Authority. Premiums shall be collected for that last month by the Authority.
(13) All Authorities with Commission coverage shall be required to take monthly deductions for enrollees one month in advance, and shall remit to the Commission on the required schedule.
(14) All Authorities shall be required to cover eligible surviving Spouses of enrollees. Surviving Spouses shall be eligible for Commission coverage, but coverage of a surviving Spouse shall end upon the surviving Spouse's remarriage.
(15) If a former Spouse is eligible under the terms of a divorce decree and enrolled under the insured's family plan, coverage for the former Spouse under the insured's family plan will end upon the remarriage of either party. The former Spouse may be eligible for a divorced Spouse rider or COBRA coverage as determined by the Commission depending upon the language in the divorce decree.
(16) Authorities' insureds who transfer to Commission coverage and are retired and eligible for Medicare shall be required to enroll in Medicare Parts A and B during the next available Medicare annual enrollment in order to receive health coverage through the Commission. Municipal Employers shall be required to notify all retirees of this obligation and of the next Medicare open enrollment period. Authorities shall not bill the Commission for any Part B premiums or late enrollment Part B penalties. Authorities shall reimburse retirees for penalties incurred by their Medicare‑eligible insureds who are required to join Medicare upon transferring to Commission coverage. The Authority is not required to reimburse retirees for late enrollment penalties if the retiree did not enroll in Medicare when required.
(17) Authorities shall gather eligibility information for enrollment and status changes, and shall forward a copy of all such documentation to the Commission. Any costs for materials that require translation shall be borne at the applicant's or Authority's expense.
(18) Authorities' insureds who terminate employment while in good premium payment standing and begin employment with benefits with another Commission Authority before coverage ends with the initial employer, shall continue to be insured without a break in coverage and must remain in the health plan they enrolled in with the first Authority. Said Insureds who began employment with benefits provided through another Municipal Employer after prior Commission coverage has ended, shall be treated as new employees subject to the required waiting period for coverage.
(19) The Commission shall determine the full cost rates for health coverage, which includes the administrative fee determined by the Commission, to be shared by the Authority and its insureds.
(20) The Authority shall arrange for all its insureds' premium contributions to be deducted from their paychecks or retirement allowance one month in advance of coverage or through the Authority's billing system, as the case may be. The Authority shall notify the Commission of any change to its Insureds' premium contribution ratios by no later than January 15th to become effective the following July 1st.
(21) The Authority shall transmit to the Commission monthly the full cost of its Insureds' health coverage, including the applicable administrative fee.
(22) The Authority shall pay premium monthly for Commission coverage, and shall include the applicable administrative fee, in full. Payment of the Authority's Insureds' health coverage is due on a date determined by the Commission. The Commission shall invoice the Authority on a monthly billing cycle for the full cost health insurance premium liability and administrative fee. Invoices will be sent electronically (via secure email) to each Authority each month; any adjustments will be separately noted on the following month's invoice. The Authority shall provide to the Commission, on a monthly basis, the premium contribution ratio paid by each of its Insureds in a format prescribed by the Commission.
(a) In the event that an Authority fails to pay the full amount within 30 days of the invoice due date, the Commission shall send an overdue notice to the Authority. Payment not received after 30 days' delinquency will be subject to interest charges and further action.
(b) The Commission shall notify the Authority and the Executive Office for Administration and Finance of the delinquency and the Commission's intention to cancel coverage if the Authority fails to pay the full amount in arrears for more than 60 days from the invoice due date.
(c) As to remaining arrearages, the Commission may inform the state treasurer who shall issue a warrant in the manner provided by section 20 of chapter 59 requiring the Authority to pay into the treasury, as prescribed by the Commission, the amount of the premium and administrative expenses attributable to the political subdivision, see M.G.L. c.58 s.20A.
(d) If any amount remains in arrears at the end of a 90-day period, the Commission may begin termination proceedings of the Authority's health coverage, and the Authority shall be responsible for all claims incurred during the period in which the full premium was not paid.
(23) Authorities shall report all changes to an enrollee's coverage on forms designated by the Commission. Upon notification from the Commission, Authorities shall be required to enter on the Commission's eligibility system (MAGIC system), an enrollee's coverage and/or coverage changes.
(24) The Commission determines the effective date of enrollees' coverage changes including, but not limited to: individual to family, family to individual, and cancellation of coverage and shall notify the Authority directly via the Premium Deduction Change Notice. The Authority shall accept this notice and update its records accordingly.
(25) The Authorities shall reconcile their entire insured membership on a monthly basis via the Statement of Verification that is included with the monthly bill and roster. Authorities shall report any discrepancies to the Commission at a time determined by the Commission. Late notification of discrepancies to the Commission may result in a delay in the effective date of insurance coverage changes.
(26) Any Authority that transfers its insureds to the Commission with more than one enrollee percentage contribution towards a particular individual, family or Medicare health plan premium shall be required to provide the Commission with enrollment data by enrollee percentage contribution for said health plan(s) each month on a form that will be provided by the Commission. This requirement does not apply to an Authority that has only two enrollee percentage contributions towards a particular individual, family or Medicare health plan premium and where one of the two percentage contributions is exclusively for those enrollees who had formerly participated in the Commission's Retired Municipal Teachers program.
(27) If an Authority chooses to transfer to Commission coverage and its retired teachers currently receive insurance through the Commission's Retired Municipal Teachers program under M.G.L. c.32A, s.12, all said retired teachers shall transfer from the Commission's fully insured Pool 2 to Pool 1 and shall re-enroll in a Commission health plan when an Authority transitions to the Commission. Retired Municipal Teachers who transfer to the Commission through their respective Authorities shall no longer be eligible for the Commission's life or retiree dental insurance coverage, and shall receive only health insurance through the Commission.
(28) The Commission shall not assume responsibility for any administration relating to municipal health reimbursement arrangements, or any other type of healthcare spending accounts for Authorities transferring to the Commission's coverage. Authorities that establish health reimbursement arrangements under M.G.L. c. 32B, s. 25 shall not be subject to the prohibitions of 805 CMR 8.01(3).
(29) A participating Authority may request data for the sole purpose of determining whether it will continue to participate after three years, as specified in its executed bargained agreement or order from the three person arbitration panel. Requests for such data shall be made in the preceding or current fiscal year in which a given agreement is open to negotiation, and such requests shall be limited to one request in the preceding or current fiscal year in which a political subdivision is considering withdrawing from coverage.
(a) Authorities requesting utilization data should assess the amount of time they will need to analyze data and conduct negotiations before making a decision about whether to remain in the Commission. Such entities must submit their requests to the Commission at least 45 days before the data are to be provided to them to use in their decision-making process. In a City, the request must be signed by the City Manager or the Mayor, in a Town by the Chairman of the Board of Selectmen, and in a regional school district, by the Chairman of the Regional School District Committee.
(b) The Commission will provide the following data to each requesting Authority with more than 50 subscribers:
A monthly claims report consisting of the following data elements: (i) the subscriber count, (ii) the covered lives count, (iii) the total paid medical claims, (iv) the total paid prescription drug claims.
A yearly large loss report, i.e., for claimants who have incurred $25,000 or more paid claims in a given year, consisting of the following elements: (i) the de-identified claimant ICD-9 codes (diagnoses), (ii) the de-identified claimant total paid claims (medical and prescription drug).
The Commission will provide Protected Health Information to participating Authorities as the Commission's Business Associates subject to the HIPAA Privacy Rule after each signs the Commission's Business Associate Agreement (BAA) .
Authorities that have requested these data will be required to designate a single person to handle these data, and such persons will be required to sign a BAA in which they agree not to share these data with other parties. Before receiving these data, the Authorities agree to execute a BAA with the Commission in which they agree that only their single designated person shall handle the data, and that the data shall not be shared with anyone other than insurance brokers, benefits consultants, and health plans for the limited purpose of securing bids for the procurement of health insurance.
Authorities wanting Medicare HMO data should use the monthly premium as a substitute for actual cost. Administrative costs are not included in the data provided.
(30) On or before January 15 in the year 2013 or any later year, at the request of an Authority, the Commission will make available to the Authority a list of that Authority’s current members. An Authority must make any such request by November 15 of the prior year. The purpose of this list is to assist the Authority in meeting its obligations under M. G. L. c. 32B, s. 26.
805 CMR 8.05: M.G.L. c.32B, s.23
This information provided by the Group Insurance Commission .