You have applied for a medical or dental insurance plan (“Plan”) offered through the Commonwealth Health Insurance Connector Authority (“Connector”). The Connector is responsible for enrolling you, billing and collecting premiums from you, sending your premiums to the Plan in which you enroll, and, when appropriate, terminating your coverage. When we use the word “Connector” in this Agreement, it means the Connector or its Agents, Designees or subcontractors.
BY APPLYING FOR AND ENROLLING IN A PLAN THROUGH THE CONNECTOR, I UNDERSTAND AND AGREE TO, ON BEHALF OF MYSELF AND MY ENROLLED DEPENDENTS, THE FOLLOWING TERMS AND CONDITIONS:
- Eligibility.
My dependents and I are eligible to purchase insurance under state and federal law and Connector policies. - Termination of Current Health Plan.
If I am currently enrolled in a Health Connector Plan, my enrollment in this new Plan indicates my request for the termination of my previous health plan. I will not have an overlap of health plan coverage through the Connector. - Enrollment Requirements.
• My enrollment in a Plan is subject to acceptance by the Issuer.
• My coverage in a Plan will begin on the first day of the calendar month selected for coverage if all documentation and payments are received by the required due date. This is called my “Effective Date”.
• If requested, I will give the Connector complete information and documentation to establish my dependents’ and my own eligibility, including, but not limited to, proof of residency, citizenship, or incarceration status. If I fail to comply with the request(s), the Connector may not be required to issue a Plan to me. I will promptly notify the Connector of any changes to my address or citizenship or residency status, and, if I am receiving any federal or state subsidies, any changes in income or access to other health insurance. I attest that I will enroll in a plan only with my eligible dependents, in accordance with Connector policy and state law. My dependents eligible to enroll with me may or may not be part of my tax household. - Plan Selection.• I am free to select among any of the Plans offered by the Connector as long as I meet the eligibility requirements for enrolling in that Plan.
• Each Plan has its own written description of the benefits, terms and conditions that will apply to people enrolled in that Plan. This description is in a booklet usually called an “Evidence of Coverage”booklet?When I am accepted for enrollment in a Plan, my coverage will be provided according to all the terms and conditions of that Plan’s Evidence of Coverage. The Issuer and not the Connector will:
i. provide me with an Evidence of Coverage; and
ii. provide me coverage for medical or dental benefits according to that Evidence of Coverage. - Coverage Period.
• For Platinum/Gold/Silver/Bronze Health Plans and ConnectorCare Plans.
i. My coverage will end on the date indicated in my account.
ii. Once my coverage is effective, I cannot change to a different Plan outside of the open enrollment periods, as defined by state or federal law, unless an exception applies or I experience a triggering event in accordance with state and federal law.
iii. If I become eligible for employer-sponsored coverage through the Connector, I may switch to that Plan regardless of the date.
• For Catastrophic Plans.
i. My coverage will end on the date indicated in my account..
ii. If my 30th birthday occurs prior to the coverage end date and I do not have a Certificate of Exemption granted on the basis of financial hardship or a lack of affordable coverage available to me, I may remain in the Catastrophic Plan until my renewal date, be disenrolled at the end of my plan year, or be offered an Individual/family non group plan prior to my termination date.
iii. Once I am enrolled, I cannot change to a different Catastrophic Plan, except as permitted by state or federal law and Connector policies.
iv. If I become eligible for employer-sponsored coverage through the Connector, I may switch to that plan regardless of the coverage end date.
• For Dental Plans
i. My coverage will last twelve (12) months from the date of enrollment.
ii. If I become eligible for employer-sponsored coverage through the Connector, I may switch to that Plan regardless of the date.
iii. I understand that if I cancel coverage, I may not be able to repurchase a dental plan through the Health Connector for a period of time, depending on my Plan Issuer’s policies. - Annual Deductibles and Out-of-Pocket Maximums
If I change health or dental plans, I will be subject to the new deductible and out of pocket maximum of that plan. - Payment and Related Terms.
• I agree to pay the monthly premium for the Plan that I select. I also agree to pay any applicable Connector-imposed fees related to my monthly premium payments, such as fees for non-sufficient funds, wire transfer fees, or reinstatement fees, if applicable.
• The Connector will bill me once a month. This bill will be sent to me approximately thirty (30) calendar days before the applicable coverage month. (For example, on July 1st the Connector will send me a bill for my August coverage.) The bill will state the premium as well as any fees I have incurred for the applicable coverage month.
• I agree to pay the Connector so that the premium is received on the 23rd calendar day of the month before coverage effective date(“Due Date”).
• The amount of my monthly premium will not change during my coverage period, unless I add or remove dependents. However, if I am receiving tax credits or other subsidies, the amount of the premium that I pay may change if I adjust my federal tax credit amount or if my eligibility changes. Changes in my premium payment will never be based on my dependents’ or my health status or our use of medical services.
(Please note, premium rates charged by health and dental insurance Issuers are subject to review by the Massachusetts Division of Insurance (DOI) and could change per DOI order.)
• I understand that if I was incorrectly enrolled in a ConnectorCare plan, for example, because I provided inaccurate information, the Health Connector may recover any state subsidies paid on my behalf. - Cancellation and Termination.
• I may cancel my coverage at any time by notifying the Connector no later than the 23rd of the month by phone, fax, email, or regular mail. My coverage will end on the last day of the calendar month in which I notify the Connector, as long as I make my request by the 23rd of the month. I am not permitted to cancel my coverage retroactively (back in time). If I cancel my coverage, I am responsible for paying the premiums up until the effective date of my cancellation”
• For persons receiving non-subsidized coverage, if the Connector does not receive my full premium by the due date indicated in the Notice of Delinquency, then the coverage is terminated on the day following that date when my account is two months past due. The coverage end date is retroactive to the last day of the coverage month for which my monthly premium was paid in full in accordance with Connector policies.
For subsidized coverage (receiving any state or federal subsidies), if the Connector does not receive my full premium by the due date indicated in the Notice of Delinquency, then the coverage is terminated on the day following that date. The coverage end date is retroactive to the last day of the first coverage month in which I was delinquent (i.e. one month grace period) in accordance with Connector policies.
If my coverage is terminated, I may be entitled to have my coverage reinstated with the same Plan and Issuer if my coverage has not lapsed for more than thirty (30) days from the termination date. To do so, I must pay all overdue premiums, the current month’s premium, and any fees, if applicable, including charges due to insufficient funds, wire transfer fees, and reinstatement fees.
a. The Connector may cancel my Plan if:
I. I fail to pay my premiums;
II. I commit fraud;
III. I misrepresent my dependents’ or my eligibility for the Plan or specific benefits of the Plan;
IV. I misrepresent any information relevant to my enrollment in the Plan;
V. I fail to comply in a material manner with the Plan requirements, including, but not limited to, by moving outside of the Carrier’s service area; or
VI. My mail is returned as undeliverable and I do not confirm my correct address with the Health Connector.
The Connector will provide written notice of the effective date of the Plan’s cancellation and I will be responsible for the cost of any medical care services that I or my dependents receive after that date. - Connector Policies and Procedures.
I may request from the Connector a copy of any detailed enrollment, billing or payment policies and procedures. These policies and procedures are considered a part of this Terms and Conditions Agreement. - Amendments
The Connector may amend these Terms and Conditions from time to time. The Connector shall provide me with notice of such amendment and its effective date. - Limitation on Liability.
Neither the Connector nor its Agent, Designee, or subcontractor shall have any liability or responsibility whatsoever to me, my enrolled dependents, or any third party:
a. If I do not pay my premium to the Connector in accordance with this Agreement; or
b. Based on the acts or omissions of:
I. the Issuer with respect to its provision of coverage for medical benefits due, or alleged to be due, to me or my enrolled dependents under that Plan; or
II. any health care provider who provides health care services to me or my enrolled dependents under the Plan. - Waiver.
The Connector’s exercise or non-exercise of any of its rights under this contract on any occasion shall not be construed as a waiver of any of my obligations nor shall it obligate the Connector to act in a similar fashion on any later occasion. - Governing Law.
This Agreement and the rights and obligations of you and the Connector will be governed by and interpreted in accordance with the laws of the Commonwealth of Massachusetts, without giving effect to its choice of law rules. - If you are choosing a plan that has been designated as a limited network plan, the following applies to you:
• The plan you have chosen provides access to providers that are not the same as the carrier’s general provider network.
• You understand that you may not change plans during a policy year because of changes to the provider network.
• You understand that the plan provides access to providers that may not the same as the carrier’s general provider network.
• You have reviewed the provider directory or online provider search tool for the plan you have selected and understand that this plan only provides access to covered benefits for the providers in that provider directory.
• You understand that it is your responsibility to ensure that a provider you voluntarily choose is enrolled in the plan’s provider network prior to obtaining care.
• In choosing the limited network plan, you understand that you will be required to choose a different provider for treatment if a provider you now see is not enrolled in the plan’s provider network.
• You have received a guide to limited network plans that is accessible at
https://www.mahealthconnector.org/limited - ACCEPTANCE OF THIS AGREEMENT.
EITHER (1) MY VERBAL CONSENT GIVEN TO THE CONNECTOR OR (2) PAYMENT OF MY FIRST MONTH’S PREMIUM AFTER A COMPLETED APPLICATION IS ACCEPTED BY THE CONNECTOR IS DEEMED TO BE ACCEPTANCE OF THIS AGREEMENT ON BEHALF OF ANY DEPENDENTS AND MYSELF.
By signing this agreement, you are also agreeing to the following statements:
You understand that because advance payments of the premium tax credit will be paid on your behalf to reduce the cost of health coverage for yourself and/or your dependents:
- You must file a federal income tax return in 2023 for the tax year 2022.
- If you are married at the end of 2022, you must file a joint income tax return with your spouse.
- You also expect that:
- No one else will be able to claim you as a dependent on their 2022 federal income tax return.
- You will claim a personal exemption deduction on your 2022 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments.
If any of your information changes, you understand that it may impact your ability to get an Advance Premium Tax Credit. You also understand that when you file your 2022 federal income tax return, you must reconcile the amount of advance payments actually made with the amount of any premium tax credit you are entitled to receive. You understand that if the amount of the advance payments made on your behalf is less than the amount of any premium tax credit you are entitled to receive, you may be entitled to an additional credit amount.
Alternatively, if the amount of advance payments made on your behalf exceeds the amount of any credit you are entitled to receive, you may owe additional federal income tax.
You understand that failure to make the first premium payment towards your policy to the Massachusetts Health Connector could result in a delay in the start of your plan or cancellation of your enrollment.
You understand that providing this payment information does not guarantee approval or coverage. The Health Connector must process your enrollment request. Please contact the Massachusetts Health Connector if you have any questions or concerns.