805 CMR 8.03 - Eligibility, Conditions of Participation

(1) To be eligible for Health Coverage, persons affiliated with Municipal Employers must be Employees, Retirees, Survivors, or Dependents, as those terms are defined in 805 CMR 1.02: Definitions.

(2) For the purposes of implementing M.G.L. c. 32B, §§ 19 and 23, the Commission interprets M.G.L. c. 32B, §§ 19(a) and (e) and 23(h) to mean that eligibility for Health Coverage in political subdivisions that have transferred subscribers to the Commission pursuant to M.G.L. c. 32B, § 19 or 23 remains subject to M.G.L. c. 32B. However, for those political subdivisions, the Commission is the sole determinant of who is eligible for Health Coverage. The Commission interprets eligibility under M.G.L. c. 32B to be the same as eligibility under M.G.L. c. 32A, except where there is a clear distinction between the two chapters. Therefore:

(a) Consistent with 805 CMR 9.08: Employees and Municipal Insureds not Entitled to Receive a Pension or Retirement Allowance and 805 CMR 1.02: Employee and Retiree, the employees and retirees of a city, town, regional school district, 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 Municipal Employees or Retirees (OBRA is not such a public retirement system for this purpose).

(b) Municipal Employees, except elected officials or others as expressly exempted by law, must meet the requirement of a Regular Work Week, as defined in 805 CMR 1.02: Definitions. For the purposes of M.G.L. c. 32B, §§ 19 and 23, the reference to "20 hours" in M.G.L. c. 32B, § 2, "Employee" means 20 hours out of a regular work week of 40 hours, or 18.75 hours out of a regular work week of 37.5 hours.

(3) The following individuals are Municipal Employees:

(a) Elected officials, without regard to hours worked or to participation in a pension system, are Municipal Employees at local option, consistent with 805 CMR 9.02: Elected Officials and M.G.L. c. 32B, § 2, "Employee".

(b) Members of call fire departments or other emergency services, without regard to hours worked, are Municipal Employees at local option, consistent with M.G.L. c. 32B, § 2, "Employee".

(c) Public school employees are deemed to be Employees during the months of July and August following the school year, without regard to hours worked or to method of payment pursuant to M.G.L. c. 71, § 40 and eligible for coverage if employee contributions for health insurance for those two months are deducted from the compensation paid for services rendered during the previous school year consistent with M.G.L. c. 32B, § 2.

(d) Traffic supervisors, without regard to hours worked, are Municipal Employees at local option, consistent with M.G.L. c. 32B, § 2A.

(e) Reserve, permanent-intermittent, and call firefighters, without regard to hours worked, are Municipal Employees and, upon retirement, Municipal Retirees, at local option, consistent with M.G.L. c. 32B, § 2B.

(4) The Commission shall determine the effective date for all matters pertaining to Municipal Insureds' Health Coverage, including but not limited to their eligibility, effective dates of coverage, termination, and status changes. The Commission determines whether persons are eligible for Commission coverage as Municipal Insureds according to M.G.L. c. 32A and c. 32B, and its eligibility decisions are final and binding. Prior coverage through a Municipal Employer does not guarantee Commission coverage.

(5) Municipal Employers 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 pended until such time as the Commission can determine an appropriate date.

(6) The Municipal Employer shall submit all eligibility and enrollment information requested by the Commission, including census data in a format specified by the Commission, along with documentation that the Commission deems necessary to determine eligibility.

(7) A Municipal Employer's authorized individual shall certify the accuracy of the eligibility information and shall submit the certification, signed under the pains and penalties of perjury, with the eligibility data for the Commission's review and decision. No persons shall be enrolled in Commission coverage without the prior approval of the Commission.

(8) Surviving Spouses of Municipal Employees and Municipal Retirees are eligible for Commission coverage, subject to the provisions of 805 CMR 9.09: Surviving Spouse. Health Coverage for Municipal Employees' and Retirees' surviving spouses ends upon the surviving spouse's remarriage.

(9) Municipal Insureds and their eligible dependents shall be eligible for Health Coverage and shall be subject to the same Health Coverage terms, conditions, carriers, schedules, benefits and benefit levels as those provided to State Employees, Retirees, Survivors, and their Dependents in the pool.

(10) The Commission may audit Municipal Employers for compliance with the Commission's policies and procedures for maintaining Municipal Insureds' Health Coverage.

(11) If they are eligible for Medicare Part A for free, Municipal Retirees, their covered spouses, and Municipal Surviving Spouses are required to enroll in Medicare Parts A and B in order to receive health coverage through the Commission. They must enroll during Medicare's next annual enrollment period. Municipal Employers shall be required to notify all retirees of this obligation and of the next Medicare open enrollment period. The Municipal Employer shall pay any new late entry penalties for its Medicare-eligible Insureds who were required to join Medicare as a condition of transfer to Health Coverage. The Commission shall not pay for or reimburse any Part B premium. Municipal Employers shall reimburse retirees for penalties incurred by their Medicare eligible insureds who are required to join Medicare upon transferring to Commission coverage. A Municipal Employer is not required to reimburse retirees for late enrollment penalties if the retiree did not enroll in Medicare when required.

(12) Upon the Municipal Insureds' Coverage effective date and for the duration of their Health Coverage, the Insureds shall not receive health coverage pursuant to M.G.L. c. 150E, M.G.L. c. 32B or any other arrangement with the Municipal Employer.

(13) The Municipal Employer shall perform all administrative functions and shall process and provide all information that the Commission deems is necessary to administer its Insureds' Health Coverage, including monthly billing reconciliation.

(a) The Municipal Employer and its Insureds, as the case may be, shall furnish all information necessary to maintain its Insureds' Health Coverage in such form, content and frequency as the Commission determines, including but not limited to monthly reconciliation of the Commission's monthly billing file.

(b) The Municipal Employer shall gather eligibility information for enrollment and status changes, and forward a copy of all such documentation to the Commission with each application. Any necessary translation shall be at the applicant's or Municipal Employer's expense.

(14) Municipal Insureds who terminate employment while in good premium payment standing and begin employment with benefits with the same or another Employer before Commission coverage under the prior Municipal Employer ends, shall continue to be insured without a break in existing coverage and must remain in the health plan they enrolled in with the first Municipal Employer consistent with 805 CMR 9.19(1). Such Municipal Insureds who begin employment with benefits with the same or another Employer after Commission coverage under their prior Municipal Employer has ended shall be subject to 805 CMR 9.19(2).

(15) The Commission is not subject to the provisions of M.G.L. c. 30A.

(16) Prior to the effective date of transfer to the Commission's health coverage, the Municipal Employer 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 Municipal Employer's health coverage. The Municipal Employer's Insureds shall be offered the same health plan choices offered to state Insureds who reside in the same geographic area.

(17) Coverage ends on the last day of the calendar month following the month that an employee leaves the service of his or her original Municipal Employer. Premiums shall be collected for that last month by the Municipal Employer.

(18) 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 the Insured or Spouse. 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.

Notes

805 CMR 8.03

Amended by Mass Register Issue 1310, eff. 4/8/2016. Amended by Mass Register Issue 1450, eff. 8/20/2021.