Appeal and Waivers
As T1 agents, do we advise members to make an appeal
NO
What is Closed Enrollment
Closed enrollment is known as the period outside of Open Enrollment. Anyone can apply, however, not everyone may be eligible to shop and enroll.
What information is required to fully authenticate the HOH?
Both the first and last name, The full date of birth, f the HOH’s SSN is on file, this must be provided! NO EXCEPTIONS.
Review Request for Information (RFI) details, Acceptable Documentation, and ways to submit
Eligibility
3 Customer Types
ConnectorCare,
APTC-Only
Unsubsidized
2 reasons that would make members unable to appeal
• Termination for non-payment of premium/ Payment Inquiries • Customer Service Complaints • Health plan-specific complaints (covered services or network) • Retro-Enrollment • Reinstatements • Voluntary – Retro Termination • 1095 Forms Double Coverage • Dental Eligibility
when does closed enrollment begin
Jan 24th
If the HOH does not have a Social Security Number on file in HIX, what are the two alternative pieces of info that can be used
The Subscriber ID & The Full Mailing Address
Assist with a Binder payment
Plan Shopping
What does Maximum Out-of-Pocket (MOOP) mean
the most a member will pay during the plan year out-of-pocket for cost-sharing in-network health and dental services
4 Ways to submit an appeal
online, phone, mail, fax
If an individual qualifies for a SEP, and their “window” opens, they have up to how many days to enroll in a plan
60 days
What does PSI stand for
Permission to share Information Form
Address any premium balance issues
Billing and Payments
What is the dummy SSN and when do we use it
132-45-7689
Submitting a Non-HIX Dental Application for
Members with NO Social Security Number
3 examples of financial hardship
homeless, rent/mortgage, eviction, utilities, expenses, bankruptcy
what are 3 examples of an QLE
Marriage, Adoption, Foster Care, Connector Care Qualification, American Indian or Alaska Native, Lawful Presence, Loss of MEC, Birth, Moved into MA
What does CDF stand for
Certified App. Counselor Designation Form
Create an Account
Tech Support
name 3 change categories that comes with the new 25/26 update
MassHealth Start Date Rules
Multi-Language Support for Invite Client
Standalone Dental Plans for 2026 Applications
Tax Filer/ Tax Dependent Status
what is Office of Patient Protection (OPP) Waiver
During closed enrollment, if an applicant or member doesn’t have a Qualifying Life Event (QLE) to give them a Special Enrollment Period (SEP), or they didn’t enroll during their 60-day SEP or are not able to reinstate, they may be able to apply for a waiver from the Office of Patient Protection (OPP) to be able to enroll in coverage prospectively.
should t1 agents refer members to OPP directly
NO, if they insist, a case for tier 2 should be created.
How long does it take to process forms
3-5 bus days
Provide Health and Dental Insurance Carriers that are partnered with the Health Connector
General Inquiry
What is the lockout period for both Delta and Altus
Hint: they are different
Altus: 24-month lock-out
Delta Dental: 12-month lock-out