Provencal v. Commonwealth Health Insurance Connector Authority
Provencal v. Commonwealth Health Insurance Connector Authority
Opinion of the Court
On May 5, 2008, Daniel and Diane Provencal commenced this action in the Superior Court by filing a complaint for judicial review against the Commonwealth Health Insurance Connector Authority (authority), its executive director, and the chairperson of its board (collectively, the defendants) after the Provencals were deemed ineligible to participate in the Commonwealth Care Health Insurance Program (Commonwealth Care) because they had access to employer-subsidized health insurance (ESI). The defendants filed a motion to dismiss the complaint pursuant to Mass. R. Civ. P. 12 (b) (1) and (6), 365 Mass. 754 (1974), which was allowed. The Provencals appealed, and we granted their application for direct appellate review. For the reasons that follow, we now affirm.
1. Statutory and regulatory framework. In 2006, the Legislature enacted a sweeping health care reform act entitled, “An act providing access to affordable, quality, accountable health care,” St. 2006, c. 58 (the Act), the purpose of which, as set forth in the preamble, was “to expand access to health care for Massachusetts residents.” Among its many provisions, the Act requires that all adult residents of the Commonwealth obtain and maintain health insurance “so long as it is deemed affordable.” G. L. c. 111M, § 2 (a), inserted by St. 2006, c. 58, § 12. To that end, the Act created the Commonwealth Health Insurance Connector (connector), see G. L. c. 176Q, inserted by St. 2006, c. 58, § 101, the purpose of which is “to facilitate the availability, choice and adoption of private health insurance plans to eligible individuals and groups.” G. L. c. 176Q, § 2 (a).
Responsibility for implementation of the connector is vested in the authority, an independent public entity “not subject to the supervision and control of any other executive office, department, commission, board, bureau, agency or political subdivision of the commonwealth except as specifically provided in any general or special law.” Id. The connector is governed by a
In an effort to give low-income residents access to affordable health insurance, the Act created Commonwealth Care, see G. L. c. 118H, inserted by St. 2006, c. 58, § 45, a program designed to “redue[e] uninsurance” in Massachusetts by “providing] subsidies to assist eligible individuals in purchasing health insurance.” G. L. c. 118H, § 2. Commonwealth Care is administered by the board of the connector. See id. See also G. L. c. 176Q, § 7. The Legislature has delineated, with specificity, the eligibility criteria for participation in Commonwealth Care. General Laws c. 118H, § 3 (a), provides:
“An uninsured individual shall be eligible to participate in the program if:
“(1) an individual’s or family’s household income does not exceed 300 per cent of the federal poverty level;
“(2) the individual has been a resident of the commonwealth for the previous 6 months;
“(3) the individual is not eligible for any MassHealth program, for Medicare, or for the child health insurance program established by [G. L. c. 118E, § 16C];
“(4) the individual’s or family member’s employer has not provided health insurance coverage in the last 6 months for which the individual is eligible and for which the employer covers at least 20 per cent of the annual premium cost of a family health insurance plan or at least 33 per cent of an individual health insurance plan;[4] and
*509 “(5) the individual has not accepted a financial incentive from his employer to decline his employer’s subsidized health insurance plan.”
Additionally, G. L. c. 118H, § 3 (b), states that the board of the connector may waive § 3 (a) (4) if the individual’s employer complies with enumerated statutes that prohibit group insurance plans that charge higher premiums to lower-wage employees. See G. L. c. 175, § 110 (O); G. L. c. 176A, § 8V2; G. L. c. 176B, § 3B; G. L. c. 176G, § 6A. In the event of a waiver, the employer’s health insurance premium contribution for the applying individual shall be paid to the connector. See G. L. c. 118H, § 3 (b). Pursuant to G. L. c. 118H, § 4, all Massachusetts residents have the right to apply to participate in Commonwealth Care, to receive a written determination detailing denial of eligibility, and to appeal from any eligibility decision, “provided such appeal is conducted pursuant to the process established by the board of the commonwealth health insurance connector.” Further, applicants for Commonwealth Care “shall be eligible for subsequent appeals subject to [G. L. c.] 30A.” G. L. c. 118H, § 4.
2. Factual and procedural background. In 2007, Daniel Provencal was an employee of Brookfield Wire Company (Brookfield Wire) and earned $24,239. His wife was unable to work because of several medical conditions. Brookfield Wire offered health insurance to its employees and, during the time period at issue, paid at least thirty-three per cent of the cost of the annual premium. The Provencals could not afford to pay their share of the insurance premium, $196.52 every two weeks, which was nearly twenty per cent of their gross income. Therefore, they applied to participate in Commonwealth Care and thereby secure subsidized health insurance.
In a February 6, 2008, decision, a hearing officer found that the health insurance subsidy provided by Brookfield Wire appeared to disqualify the Provencals from participation in Commonwealth Care. Nonetheless, the hearing officer referred the Provencals’ appeal to the connector for a further hearing to determine whether they might be eligible for Commonwealth Care based on their inability to afford ESI.
In their subsequent complaint for judicial review, the Provencals alleged that the defendants erred and abused their discretion in refusing to give fair consideration to the Provencals’ request for a waiver of the ESI exclusion set forth in G. L. c. 118H, § 3 (a) (4). Further, they claimed that the “acts, practices and/or policies” of the defendants in failing to develop objective criteria for implementing the waiver provisions of G. L. c. 118H, § 3 (b), and 956 Code Mass. Regs. § 3.09(l)(c) (2008),
The judge, in allowing the defendants’ motion to dismiss,
3. Discussion. The Provencals do not challenge their ineligibility for participation in Commonwealth Care because of the ESI exclusion. The focus of their appeal is on their ability to have that exclusion waived. As such, the essence of the Provencals’ argument is twofold. They contend that the connector had a statutory duty, pursuant to G. L. c. 118H, § 3 (b), to implement a waiver program, and that the connector’s refusal to consider their request for a waiver of the ESI exclusion was a part of their eligibility determination such that they had a right to receive a written decision detailing their ineligibility and to appeal from such decision. We disagree.
While G. L. c. 118H, § 3 (a), encompasses the specifics of an uninsured individual’s eligibility to participate in Commonwealth Care, § 3 (b) relates to a slightly different inquiry, namely whether the board of the connector should waive the ESI exclusion. The Legislature has stated that the board “may waive” this exclusion if the individual’s employer complies with enumerated statutes that prohibit group insurance plans that charge higher premiums to lower-wage employees.
As the entity charged with the administration of Commonwealth Care, the connector’s view of its authority and responsibilities under G. L. c. 118H is entitled to substantial deference. See Dahill v. Police Dep’t of Boston, 434 Mass. 233, 239 (2001), and cases cited. See also Iodice v. Architectural Access Bd., 424 Mass. 370, 373 (1997). We have stated that “[w]hen the Legislature delegates to an administrative agency a broad grant of authority to implement a program of reform or social welfare, the administrative agency generally has a wide range of discretion in establishing the parameters of its authority pursuant to the enabling legislation.” Levy v. Board of Registration & Discipline in Med., 378 Mass. 519, 525 (1979). Consistent with this authority, an agency may promulgate regulations to give effect to legislative mandates. See Thomas v. Commissioner of the Div. of Med. Assistance, 425 Mass. 738, 746 (1997), and cases cited. An agency’s ability to frame implementing regulations “implies discretion concerning how to carry out a [relatively] new legislative program with reasonable flexibility and in an orderly manner, giving suitable weight to the personnel and resources available to the agency.” Brooks v. Architectural Barriers Bd., 14 Mass. App. Ct. 584, 588-589 (1982).
Here, apart from the language of § 3 (b) that the board “may waive” the ESI exclusion, no implementing regulations delineate the substantive criteria and procedural mechanisms for such a waiver.
Judgment affirmed.
We acknowledge two amicus briefs filed in support of the Provencals by Health Care for All and by the Chinese Progressive Association, the Chelsea Collaborative, the Northampton Living Wage Coalition, and Western Massachusetts Legal Services, Inc.
4To distribute more equitably the costs of health care provided to uninsured Massachusetts residents, the Act imposes a “fair share employer contribution” on employers of eleven or more “full-time equivalent employees” who make less than a thirty-three per cent contribution toward the health insurance premiums of their employees. See G. L. c. 149, § 188, inserted by St. 2006, c. 58, § 47; 114.5 Code Mass. Regs. § 16.03(d) (2009). Employers’ fair share contri
Pursuant to G. L. c. 111M, § 2, every Massachusetts resident who is
The November 30, 2007, notice also terminated the Provencals’ Medicaid benefits because a minor child had left the household. That determination was upheld by the MassHealth board of hearings, and the Provencals have not appealed that decision.
Commonwealth Health Insurance Connector Authority Administrative Bulletin 01-07 recognizes the propriety of transferring appeals from the MassHealth board of hearings to the connector for issues more properly decided by the connector.
The parties agree that the connector has granted no waivers pursuant to G. L. c. 118H, § 3 (b).
The language of 956 Code Mass. Regs. § 3.09(1) (2008) provides: “An uninsured individual who is a resident of the Commonwealth shall be eligible to participate in Commonwealth Care in accordance with [G. L.] c. 118H if: ...(c) unless waived by the Board pursuant to [G. L.] c. 118H, § 3 (b), the individual’s or family member’s current employer has not provided health insurance coverage in the last six months for which the individual is eligible and for which the employer covers at least 20% of the annual premium cost of a family health insurance plan or at least 33% of an individual health insurance plan.”
In their complaint, the Provencals also alleged that the defendants’ “acts, practices and/or policies” violated their rights under the Fourteenth Amendment to the United States Constitution and art. 10 of the Massachusetts Declaration of Rights. Because the Provencals have not pressed these issues on appeal, we do not consider them. See Sullivan v. Liberty Mut. Ins. Co., 444 Mass. 34, 38 n.9 (2005); Mass. R. A. P. 16 (a) (4), as amended, 367 Mass. 921 (1975).
Notwithstanding the fact that the Provencals’ application for participation in Commonwealth Care was denied on November 30, 2007, their complaint for judicial review (filed on May 5, 2008) refers to the versions of the regulations that were promulgated by the connector in 2008. Those are the regulations relied on by the judge below and by the parties in the present appeal. We rely on those same versions.
In 2008, the standard for reviewing the adequacy of a complaint challenged by a motion to dismiss pursuant to Mass. R. Civ. P. 12 (b) (6), 365 Mass. 754 (1974), was modified in Iannacchino v. Ford Motor Co., 451 Mass. 623, 635-636 (2008). As therein stated, a complaint must contain factual allegations sufficient “to raise a right to relief above the speculative level . . . [based] on the assumption that all the allegations in the complaint are true.” Id. at 636, quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007). Because Iannacchino v. Ford Motor Co., supra, was decided on June 13, 2008, and the defendants filed their motion to dismiss on August 18, 2008, this modified standard is controlling.
The Provencals alleged in their complaint that, to the best of their knowledge, Brookfield Wire has complied with G. L. c. 175, § 110 (O); G. L. c. 176A, § 8½; G. L. c. 176B, § 3B; and G. L. c. 176G, § 6A. The defendants have not challenged this assertion.
Pursuant to 956 Code Mass. Regs. § 3.14(2) (2008), an applicant for Commonwealth Care is entitled to a fair hearing to appeal from “any adverse eligibility decision based on an Applicant’s access to government-sponsored or employer-sponsored insurance.” As such, an applicant is entitled to challenge a denial of eligibility based on G. L. c. 118H, § 3 (a) (3) and (4). Contrary to the Provencals’ assertion, the language of 956 Code Mass. Regs. § 3.14(2) does not confer any rights on an applicant with respect to whether ESI may or may not be waived.
Pursuant to the State Administrative Procedure Act, an agency is required to conduct an adjudicatory proceeding when “the legal rights, duties or privileges of specifically named persons are required by constitutional right or by any provision of the General Laws to be determined after opportunity for an agency hearing.” G. L. c. 30A, § 1 (1). Here, there are neither statutory nor constitutional requirements that would entitle the Provencals to a hearing on the waiver of the ESI exclusion. See School Comm, of Hatfield v. Board of Educ., 372 Mass. 513, 514-516 (1977). Their right to a hearing would arise only after implementation of waiver provisions with articulated standards and criteria governing the connector’s actions. See id. at 516. The necessity of implementing a waiver program is not a judicial or quasi judicial question but is a legislative one. See generally Hayeck v. Metropolitan Dist. Comm’n, 335 Mass. 372, 375 (1957).
Pursuant to St. 2007, c. 205, § 43, the Legislature directed the connector to “publish a report on implementation of [G. L. c. 118H, § 3 (b),] including the number of eligible individuals enrolled in [Commonwealth Care] and the projected premium contribution amounts to be paid by employers.” On June 18, 2008, the executive director of the authority delivered this report to the Legislature, detailing “the estimated number of eligible individuals that could be affected, if the Board of the Connector opts to waive the statutory exclusion from eligibility for Commonwealth Care for adults who have access to ESI, the estimated cost to the program of doing so, and the projected premium contributions to be paid by employers.” The Provencals point out that the judge below allowed their motion to strike the report from the record. Thus, while we can take judicial notice of the fact that the report was submitted to the Legislature, we do not consider its specific contents. See Nantucket v. Beinecke, 379 Mass. 345, 352 (1979) (matters are judicially noticed only when indisputably true); Commonwealth v. Grinkley, 44 Mass. App. Ct. 62, 69-70 n.9 (1997) (appellate courts may take judicial notice of facts of common knowledge).
Pursuant to 956 Code Mass. Regs. § 3.14(5) (2008), applicants and enrollees in Commonwealth Care are entitled to a fair hearing to appeal “the Connector’s denial of a financial hardship waiver or renewal of a financial hardship waiver under 956 [Code Mass. Regs. §] 3.11(5).” Unlike the lack of substantive criteria and procedural mechanisms governing an ESI waiver, 956 Code Mass. Regs. § 3.11(5) (2008) sets forth the criteria for extreme financial hardship and the mechanisms for waivers of copayments.
Reference
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- Daniel Provencal & another v. Commonwealth Health Insurance Connector Authority & others
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