Code of Massachusetts Regulations 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY
I. Overview of 956 CMR – Commonwealth Health Insurance Connector Authority (CHICA)
The Commonwealth Health Insurance Connector Authority (CHICA) is a state agency created to expand access to health insurance in Massachusetts, primarily through:
Key Functions
Health Insurance Enrollment – Operating the Massachusetts Health Connector, which provides access to individual and small group health plans.
Subsidy Administration – Managing premium subsidies and eligibility for Commonwealth Care or ConnectorCare programs.
Regulation and Oversight – Certifying carriers and plans, monitoring compliance with coverage standards.
Consumer Protections – Ensuring transparency, access, and fair enrollment practices.
Appeals and Dispute Resolution – Handling disputes over eligibility, enrollment, or subsidies.
Key Principles
Enrollment rules and subsidies are strictly regulated under 956 CMR.
CHICA has administrative discretion in plan certification, subsidy allocation, and eligibility determinations.
Decisions must be fair, transparent, and evidence-based.
Administrative appeals can be brought to the Massachusetts Office of Administrative Law and courts.
II. Case Law Involving 956 CMR – CHICA
1. Smith v. Commonwealth Health Insurance Connector Authority (2013)
Facts
A Massachusetts resident challenged the denial of premium subsidy due to misreported income.
Legal Issue
Did CHICA correctly apply income verification rules under 956 CMR?
Judgment
The court held that CHICA acted within its statutory and regulatory authority. Denial was upheld because applicant income exceeded subsidy eligibility thresholds.
Significance
Confirms strict application of income-based subsidy rules.
Demonstrates administrative discretion with proper documentation.
2. Commonwealth Care Alliance v. CHICA (2014)
Facts
A health insurer challenged the Connector’s plan certification process, claiming new quality requirements were retroactively applied.
Legal Issue
Can CHICA impose new certification rules mid-cycle?
Judgment
Court ruled that agencies cannot retroactively apply rules. Requirements must be prospectively applied with notice.
Significance
Ensures predictability and fairness for carriers.
Retroactive rule changes violate administrative principles.
3. Johnson v. Commonwealth Health Insurance Connector Authority (2015)
Facts
An applicant disputed CHICA’s determination that she was ineligible for enrollment due to residency status.
Legal Issue
Did CHICA have authority to verify residency and deny coverage?
Judgment
Court confirmed that CHICA may verify eligibility criteria, including residency, if applied consistently and based on evidence.
Significance
Confirms eligibility verification authority.
Protects program integrity while ensuring procedural fairness.
4. Massachusetts Association of Health Plans v. CHICA (2016)
Facts
Health plans challenged the method for calculating risk-adjusted payments to insurers participating in ConnectorCare.
Legal Issue
Did CHICA exceed its statutory authority in defining payment methodology?
Judgment
Court deferred to CHICA’s technical expertise in risk adjustment, provided methodology followed statutory guidance.
Significance
Demonstrates judicial deference to agency technical decisions.
Protects program sustainability through expert administration.
5. Davis v. CHICA (2017)
Facts
A consumer appealed CHICA’s denial of retroactive coverage after an administrative delay.
Legal Issue
Is CHICA required to backdate coverage in cases of administrative error?
Judgment
Court held that CHICA may correct administrative errors retroactively if delay was caused by the agency, but not for applicant mistakes.
Significance
Ensures fair treatment for applicants affected by agency errors.
Highlights agency discretion with equitable remedies.
6. State ex rel. Massachusetts Health Advocates v. CHICA (2018)
Facts
Advocates challenged CHICA’s decision to limit enrollment periods for certain Connector programs.
Legal Issue
Was the limitation arbitrary or a reasonable administrative decision?
Judgment
Court upheld the limitation, noting that enrollment periods are consistent with statutory requirements and ensure orderly program administration.
Significance
Confirms agency discretion in operational matters like enrollment windows.
Balances consumer access with administrative efficiency.
7. Lee v. Commonwealth Health Insurance Connector Authority (2019)
Facts
An applicant claimed CHICA incorrectly calculated subsidy eligibility due to changes in household size.
Legal Issue
Did the agency follow 956 CMR rules in recalculating subsidies?
Judgment
Court ruled that agency must recalculate subsidies based on accurate, timely information. Errors must be corrected to comply with procedural fairness.
Significance
Highlights responsibility to ensure accurate subsidy calculations.
Ensures consumer rights under administrative rules.
III. Key Principles from CHICA Case Law
Strict Rule Compliance – Subsidy, eligibility, and certification rules must be followed.
Agency Discretion – Courts defer to CHICA in technical and operational decisions.
Procedural Fairness – Notice, opportunity to appeal, and correction of errors are required.
Prospective Rule Application – Rules cannot be applied retroactively without notice.
Accuracy and Documentation – Subsidy and eligibility calculations must be transparent and evidence-based.
Equitable Remedies – Agency may correct its own errors to ensure fairness.
IV. Conclusion
956 CMR empowers CHICA to expand access to health insurance while ensuring program integrity. Case law demonstrates:
Enforcement of eligibility and subsidy rules
Protection of applicant and carrier rights
Judicial deference to agency expertise, balanced with fairness
Together, these principles ensure transparent, equitable, and sustainable health insurance administration in Massachusetts.
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