28. How do you appeal a decision by the Health Connector?

For most issues subject to appeal, the Connector will send a written notice of its decision, the reason for its decision, appeal rights and a form for appealing the decision. It must receive the request for appeal within 30 days of the date that the individual receives the adverse notice. It presumes the individual received the notice within 5 days of mailing. In an appeal from an action taken without notice, the individual has 120 days from the date of the action or failure to act to appeal. 956 CMR 12.13

The Appeals Unit receives and reviews appeals but individual appeals are heard by private attorneys under contract with the Health Connector. Appeals are generally conducted by telephone and use the procedures for informal hearings set out in 801 CMR 1.02. 

A decision of the hearing officer is final unless the director of the Appeal Unit orders a re-hearing for good cause either at the request of the appellant or on her own initiative. A request for re-hearing stays the initial decision of the hearing officer for purposes of judicial review until a decision is made by the director or her designee. 956 CMR 12.15

Fair hearing decisions by the Connector are subject to judicial review under G.L. c. 30A section 14. 

Federal regulations also provide a right to appeal to the HHS Appeals Entity within 30 days of a final decision from the Connector hearing officer. 45 CFR 155.520(c).  The Federal Appeals Entity also hears appeals from the 38 states that do not have a state-based Marketplace like Massachusetts and instead use the Federal Marketplace.