Massachusetts Health Insurance Guide
Massachusetts Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
Massachusetts reputedly supplied the template for the new federal health insurance reform act. The Massachusetts health care reform law, enacted in 2006, requires that nearly every resident to obtain health insurance coverage, although health care is provided free for residents earning less than 150% of the federal poverty level (FPL) and is partially subsidized on a sliding scale for residents earning up to 300% of the FPL. Under the Individual Mandate provision, residents 18 or older must purchase health care insurance that the state deems to be affordable for their income level. Penalties for failure to comply can be assessed on personal state income taxes.
Massachusetts is a guarantee issue state. Individual and group policies may not be medically underwritten and one can be denied coverage because of current or past health conditions. Insurers who sell individual plans are required to offer a standardized policy to all applicants. These plans are available as Medical Plan Options, Preferred Provider Plan Options and Managed Care Plan Options. All options must offer comprehensive coverage that includes physician care, maternity care, preventive care, prescription drugs, immunizations and hospitalization. Insurers are permitted six-month exclusionary and look-back periods for pre-existing conditions, but credit for prior coverage must be granted if there has been no more than a 63 day break in coverage. Insurers must base premiums on a modified community rating system, which may vary based on location, family size and age. Sex, health status and occupation cannot be used to determine rates on individual health policies issued in Massachusetts.
No small group can be denied health insurance because of their collective health history. Insurance must be offered by an employer to anyone who works 35 or more hours per week within Massachusetts, regardless of where they may live. Offering health care coverage to independent contractors, temporary workers and seasonal employees is at the employer’s discretion. Types of plans that must be offered and the amount of employer contribution vary, and are based on the number of employees. Employers may impose a waiting period. An exclusionary period of six months and a six-month look-back period may be imposed on new hires who can’t show proof of prior creditable coverage. Massachusetts’s group health insurance rates are community based. They can vary depending on group size, industry, location, family composition, the percentage of employees participating in the plan and age. Groups that take part in wellness programs may take advantage of discounted rates.
Massachusetts is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. Insurers may not raise your premiums unfairly because of your claims’ history or health status.
Massachusetts Mandated Health Benefits
Massachusetts laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism
- Blood Lead Poisoning
- Bone Marrow Transplants
- Breast Reconstruction
- Cervical Cancer and HPV Screening
- Clinical Trials
- Contraceptives
- Diabetes Supplies
- Emergency Services
- Hair Prostheses
- Home Health Care
- In Vitro Fertilization
- Mammography
- Mastectomy
- Maternity and Maternity Stays
- General and Parity Mental Health
- PKU/Formula
- Prescription Drugs
- Prostate Cancer Screening
- Rehabilitation Services
- Well-Child Care
- Coverage for newborns under their parent's policy
- Coverage for adopted children under theirs parent's policy
- Coverage for handicapped and continuation/dependents under their parent's policy
- Coverage for dependent students under their parent’s policy
- Coverage for continuation/employees
- Coverage for domestic partners
Types Health Insurance Plans Available in Maryland
The following major medical health insurance plans are generally available in Maryland. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in Massachusetts
MassHealth
The MassHealth program provides comprehensive health insurance and premium payment assistance for low-income children, families, seniors and people with disabilities.
Massachusetts Childrens' Medical Security Plan
CMSP provides health coverage for uninsured resident children under the age of 19 regardless of family income level or immigration status who do not qualify for MassHealth. Coverage is comprehensive. An ID card is issued and children may obtain service through a network of medical facilities that accept CMSP subscribers. Monthly premiums, based on family income, range from nothing to under $40 per month. Co-pays range from $2 to $8 for pharmacy, non-preventive care and dental care. Eligibility is reviewed and renewed annually. Waiting periods may apply.
Regulating Agency
The Massachusetts Division of Insurance is responsible for regulating Louisiana’s health insurance industry.
Get access to Massachusetts health insurance quotes from http://www.einsurance.com/health-insurance.
Consumer Affairs and Business Regulation
Division of Insurance
1000 Washington Street, Suite 810
Boston, MA 02118-6200
(617) 521-7794
http://www.mass.gov/?pageID=ocahomepage&L=1&L0=Home&sid=Eoca
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/