956 CMR 7.00 — Small group wellness incentive program

956 CMR: COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY

956 CMR 7.00: SMALL GROUP WELLNESS INCENTIVE PROGRAM Section 7.01: Purpose 7.02: Scope 7.03: Definitions 7.04: Enrollment Eligibility 7.05: Rebate Payment 7.06: Appeals 7.07: Administrative Information Bulletins 7.08: Severability of Provisions

956 CMR 7.00 Small group wellness incentive program

7.01 Purpose

7.01: Purpose The purpose of 956 CMR 7.00 is to implement the provisions of M.G.L. c. 176Q, § 7A. 956 CMR 7.00 applies to the Small Group Wellness Incentive Program offered to certain employers by the Connector.

7.02 Scope

7.02: Scope 956 CMR 7.00 contains the Connector's regulations governing the operation of the Small Group Wellness Incentive Program, as specified in M.G.L. c. 176Q, § 7A. The Connector also promulgates other regulations and publishes other documents affecting its programs, including statements of policy and procedure, terms and conditions of participation, guidelines, administrative information bulletins and other documents as necessary.

7.03 Definitions

7.03: Definitions As used in 956 CMR 7.00, the following terms shall mean: Connector. Commonwealth Health Insurance Connector Authority established under M.G.L. c. 176Q. Director. The Executive Director of the Connector. Eligible Small Employer. Any firm, corporation, partnership or association, including a tax-exempt organization, that purchases a group health plan through the Connector for at least one but not more than 25 Qualified Employees; provided, however, that an employer shall not be an Eligible Small Employer if the employer's sole owner is the only Qualified Employee of that employer. Initially Enrolled Employees. The number of Qualified Employees enrolled in the group health plan at the time the group health plan is purchased by the Eligible Small Employer through the Connector. Qualified Employee. Any employee of an Eligible Small Employer, including an owner or a partner in a partnership, who is covered in a group health plan purchased by an Eligible Small Employer through the Connector. Rebate Payment. A payment to an Eligible Small Employer who completes enrollment and participation requirements for the Small Group Wellness Incentive Program as set by the Connector pursuant to 956 CMR 7.04 and 7.05. Small Group Wellness Incentive Program. The program authorized by M.G.L. c. 176Q, § 7A to expand the prevalence of employee wellness initiatives by small businesses. Term. The period beginning on the first of the month following an Eligible Small Employer's enrollment in the Connector's Small Group Wellness Incentive Program and extending for the subsequent 11 months.

956 CMR: COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY

7.04 Enrollment Eligibility

7.04: Enrollment Eligibility (1) To enroll in the Small Group Wellness Incentive Program and be eligible for a Rebate Payment, an employer must be an Eligible Small Employer.

7.05 Rebate Payment

7.05: Rebate Payment (1) To qualify for a Rebate Payment, an Eligible Small Employer shall: (a) provide to the Connector, or its designee, prior to the end of a Term, satisfactory documentation that the Eligible Small Employer and at least 33% of the Eligible Small Employer's Initially Enrolled Employees have met participation requirements for the Small Group Wellness Incentive Program as set by the Connector; and (b) provide to the Connector the information needed to calculate the amount of the rebate, on a form and within a time period specified by the Connector. (2) The Rebate Payment shall, subject to 956 CMR 7.05(5), equal up to 15% of the Eligible Small Employer's share of the amount paid to purchase a group health plan for Qualified Employees through the Connector. (3) The failure of an Eligible Small Group to meet the requirements of 956 CMR 7.05(1) will result in the Eligible Small Group not receiving a Rebate Payment for that Term. (4) A Rebate Payment shall be paid to an Eligible Small Employer by the Connector at least annually. (5) Rebate Payments are contingent on available funding as determined by the Connector. In the event there are insufficient funds, the Director may impose a cap on the number of Eligible Small Employers that may qualify for a Rebate Payment. (6) Rebate Payment is only available to an Eligible Small Employer for three Terms in which an Eligible Small Employer has qualified for a Rebate Payment in accordance with 956 CMR 7.05(1).

7.06 Appeals

7.06: Appeals (1) An employer may appeal a decision by the Connector that the employer does not meet the definition of an Eligible Small Employer, that the Eligible Small Employer has not met the participation requirements set forth in 956 CMR 7.05(1), or that the Connector's calculation of the amount of the Eligible Small Employer's Rebate Payment is not correct. (2) The Connector shall provide written notice to the employer of an adverse decision with respect to eligibility as an Eligible Small Employer, the Eligible Small Employer's satisfaction of participation requirements as set forth in 956 CMR 7.05(1), or the amount of the Eligible Small Employer's Rebate Payment. (3) The employer must appeal the decision to the Connector within 30 days after the receipt of the notice of the adverse decision. In the absence of evidence to the contrary, the Connector will presume that the notice was received on the third day after mailing. An employer must appeal in writing on a form designated by the Connector. (4) Appeals brought to the Connector under 956 CMR 7.06 will be heard by a hearing officer designated by the Director. Hearings will be conducted using the policies and procedures set forth for informal hearings pursuant to 801 CMR 1.02: Formal Rules or in any administrative bulletins issued by the Connector pursuant to 956 CMR 7.07. The hearing may be conducted by telephone. The decision may be made based solely on written submissions and documents. The decision of the hearing officer will be the final decision of the Connector. (5) The Connector's final decision on the appeal will be subject to an action for judicial review under M.G.L. c. 30A, § 14.

956 CMR: COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY

7.07 Administrative Information Bulletins

7.07: Administrative Information Bulletins The Connector may issue administrative information bulletins that set out policies that are consistent with the substantive provisions of 956 CMR 7.00. In addition, the Connector may issue administrative information bulletins that specify the information and documentation necessary to implement 956 CMR 7.00. The Connector may also issue administrative bulletins containing interpretations of 956 CMR 7.00 and other information to assist persons in meeting the obligations under 956 CMR 7.00.

7.08 Severability of Provisions

7.08: Severability of Provisions The provisions of 956 CMR 7.00 are hereby declared to be severable. If any such provisions or the application of such provisions or circumstances shall be held invalid or unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions of 956 CMR 7.00 or the application of such provisions or circumstances other than those held invalid. REGULATORY AUTHORITY 956 CMR 7.00: M.G.L. c. 176Q, § 7A.

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