Code of Massachusetts Regulations 805 CMR - GROUP INSURANCE COMMISSION
805 CMR – Group Insurance Commission (GIC)
1. Overview
The Group Insurance Commission (GIC), under 805 CMR, regulates health, life, dental, and other insurance benefits for:
Massachusetts state employees
Retirees
Certain public agencies and municipal employees
The regulations govern:
Eligibility and enrollment
Plan design and coverage
Premiums and co-payments
Administrative procedures for claims and appeals
The GIC ensures compliance, fairness, and efficient management of public benefits.
2. Key Provisions
A. Eligibility and Enrollment
Employees and dependents must meet eligibility criteria for participation.
Rules govern new hires, rehires, retirees, and life events (marriage, childbirth, etc.).
B. Plan Administration
GIC establishes health, dental, and life insurance plan rules, including coverage limits and exceptions.
Requires insurance carriers to adhere to claims processing standards.
C. Premiums and Contributions
State and participating employees share premium costs according to GIC regulations.
Regulations set payment schedules, payroll deductions, and employer contributions.
D. Appeals and Compliance
Members may appeal claim denials or administrative decisions.
GIC monitors compliance by insurers and employers and can enforce corrective measures.
3. Enforcement Mechanisms
Audit and Compliance Reviews
GIC audits insurance carriers, employers, and employee records for adherence to CMR rules.
Administrative Actions
GIC may require corrective actions, including plan adjustments or reimbursement.
Appeals Process
Employees or retirees may file appeals for denied claims or eligibility disputes.
GIC holds hearings, reviews documentation, and issues binding decisions.
Sanctions
Non-compliant insurers or employers may face financial penalties, plan suspension, or removal from GIC programs.
4. Illustrative Cases
Case 1 – Ineligible Dependent Enrollment
Facts:
An employee enrolled a non-eligible relative in the GIC health plan.
Issue:
Violation of 805 CMR eligibility rules.
Action:
GIC conducted a review of enrollment documentation and payroll records.
Outcome:
Dependent removed from coverage, and employee required to repay improperly claimed benefits.
Significance:
Ensures fair access and adherence to eligibility standards.
Case 2 – Improper Claims Denial by Insurer
Facts:
An insurer denied coverage for a covered procedure for several members.
Issue:
Violation of 805 CMR plan administration and claims processing rules.
Action:
GIC audited claims, reviewed plan terms, and communicated with insurer.
Outcome:
Insurer required to pay all valid claims, update claim review process, and report compliance measures to GIC.
Significance:
Protects members’ rights to coverage and fair claims processing.
Case 3 – Payroll Deduction Error
Facts:
Employees were undercharged for premiums due to payroll deduction mistakes.
Issue:
Violation of 805 CMR premium collection and contribution rules.
Action:
GIC reviewed payroll records and identified affected employees.
Outcome:
Corrected deductions implemented, and employer required to submit report on corrective actions.
Significance:
Ensures accurate premium collection and fairness among employees.
Case 4 – Failure to Maintain Required Coverage
Facts:
A municipal employer failed to provide dental coverage mandated under GIC rules.
Issue:
Violation of 805 CMR plan administration requirements.
Action:
GIC investigated complaints from employees and confirmed lapses in coverage.
Outcome:
Employer required to retroactively provide coverage, pay claims, and submit compliance plan.
Significance:
Ensures employer accountability and employee protection.
Case 5 – Misrepresentation of Plan Benefits
Facts:
An insurer misrepresented plan benefits to employees during enrollment, overstating coverage limits.
Issue:
Violation of 805 CMR requirements for transparency and accurate disclosure.
Action:
GIC reviewed marketing materials and employee enrollment communications.
Outcome:
Insurer issued corrected information, paid any claims denied due to misrepresentation, and faced financial penalty.
Significance:
Protects members from misinformation and ensures regulatory compliance.
Case 6 – Retiree Coverage Dispute
Facts:
A retiree claimed GIC failed to provide promised prescription coverage after retirement.
Issue:
Violation of 805 CMR retirement coverage rules.
Action:
GIC reviewed enrollment records, retirement paperwork, and plan documents.
Outcome:
Retiree’s coverage corrected, claims reimbursed, and internal procedures updated.
Significance:
Ensures retirees’ benefits are honored and administrative errors corrected.
5. Summary Table of Enforcement Cases
| Case | Violation | Enforcement Action | Significance |
|---|---|---|---|
| Ineligible Dependent | Non-eligible enrollment | Dependent removed, repayment | Fair access to benefits |
| Improper Claims Denial | Insurer denied covered procedures | Claims paid, compliance plan | Members’ rights protection |
| Payroll Deduction Error | Undercharged premiums | Corrected deductions, report | Accurate contributions |
| Employer Coverage Lapse | Failure to provide dental coverage | Retroactive coverage, compliance plan | Employer accountability |
| Misrepresentation of Benefits | Overstated coverage | Corrected materials, claims paid, penalty | Transparency and member protection |
| Retiree Coverage Dispute | Missing prescription coverage | Coverage corrected, claims reimbursed | Retiree rights enforcement |
6. Key Takeaways
805 CMR ensures state employee and retiree benefits are administered fairly and accurately.
Enforcement mechanisms include audits, corrective actions, appeals, fines, and plan adjustments.
Cases highlight eligibility compliance, accurate claims processing, premium collection, employer accountability, transparency, and retiree protections.
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