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Hearing Monday On "Open Enrollment" Waiver Regulations

Hearing Monday On "Open Enrollment" Waiver Regulations

January 4, 2011

Last August's health insurance law included an "open enrollment" provision, although a more helpful name for most people would be calling it the "closed enrollment" provision. The provision closes the individual insurance market except during specified periods of the year. For 2011, individuals can by health insurance from January 1 through February 15, and again from July 1 through August 15. Starting in 2012, the market will be closed except for one open enrollment period from July 1 through August 15. This is a major change from previous Massachusetts law, which had allowed individuals to start coverage at any time.

The goal is to stop the practice insurers call "dumping and jumping" - people getting coverage just when they need expensive services. A study found that this was adding about 1% to the cost of coverage.

The law provides for a number of exceptions. Employer coverage, MassHealth and Commonwealth Care are exempt, and individuals can buy insurance when they marry, have a child, change jobs, lose COBRA eligibility or so on. In general, one can purchase coverage if it is within 63 days of involuntarily losing coverage or becoming eligible.

HCFA also advocated strongly for a general waiver provision, to exempt people who were not deliberately gaming the system. The legislature included the waiver provision that allows the Office of Patient Protection (OPP) within DPH to grant a waiver to someone who did not intentionally forgo enrollment into coverage for which the individual is eligible and met MCC standards.

In mid-December, OPP proposed regulations (text of regulations, explanatory memo (Word)) for administering the waiver process. The regulations include:

  • An individual must first apply and get turned down by an insurance carrier in order to apply for a waiver. The waiver request must then be submitted within 30 days.
  • Carriers will provide eligible individuals with the form they need to submit to OPP for a waiver.
  • OPP will not charge a fee for processing of these waivers.
  • The OPP will look at extenuating circumstances that prevented an individual from enrolling in a health plan during the previous open enrollment period, but will not consider the person's health status. They will also see if the person's reason for not enrolling is close to the exemptions allowed by the Division of Insurance’s regulation. These regulations have not been released.
  • The OPP will not hold an in-person hearing for waivers and has up to 30 days to make a decision. Once the decision is made, the individual will then bring the decision to a carrier who must enroll them within 30 days of receipt of the OPP’s decision.

The public hearing on these regulations will be Monday, January 10th at 10am in the Public Health Council Room at 250 Washington Street, Boston.

These regulations are critically important to protect people who get caught in a regulatory bind despite good intentions. A safety valve process should be easy to navigate and give people the benefit of the doubt. In our complex world, inadvertently missing an obscure 63-day deadline should not damage one's health and access to needed care. We are hopeful that DPH will consider the compassionate legislative intent behind the waiver regulation.
-Georgia Maheras and Brian Rosman