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Massachusetts Health Insurance Guide

Massachusetts Health Insurance Information, Resources and Access to Online Health Insurance Quotes
As a Massachusetts resident you can choose from health insurance plans offered to individuals and groups by private insurance companies. You may also purchase individual and family coverage from participating private insurers through Massachusetts Health Connector, the state-run exchange. If you are self-employed with no employees, you can also use the state exchange to purchase coverage. You may also be entitled to certain state and federal programs such as Medicaid, CHIP or Medicare.

Massachusetts and the Patient Protection and Affordable Care Act of 2010
The Patient Protection and Affordable Care Act (also known as ObamaCare and the Affordable Care Act and referred to in this guide as ACA) became law in 2010. Provisions of the law have continued to be phased in following passage. As of January 1, 2014, most U.S. citizens and legal residents are required by law to have qualifying health care coverage or pay an annual tax penalty for every month they go without insurance. This is called the "individual mandate." There is a grace period through March 31, 2014. Beginning in 2014, the penalty for not having qualifying coverage is $95 per adult and $47.50 per child or 1% of your taxable income, whichever is higher (up to $285 per family). The penalty increases annually through 2017 and beyond.

Individual Mandate Exemptions
You may be exempt from the individual mandate and tax penalties if:

  • You have religious objections
  • Are in the U.S. illegally
  • Are in jail
  • The cost of coverage exceeds 8% of your household income
  • Your income is below 100% of the poverty level
  • You have hardship waivers
  • You are not covered for fewer than three months during the calendar year

About Massachusetts Health Connector - The State Healthcare Exchange
Any legal Massachusetts resident, except for legal minors, can buy healthcare coverage through the state exchange. However, if you have access to affordable, qualifying coverage from another source such as an employer or government program, you may not qualify for financial assistance from KYnect. You can apply online at https://www.mahealthconnector.org/, by calling 877-623-6765 or in person.

Massachusetts Small Business Coverage
If you own a small business in Massachusetts (50 or fewer full-time-equivalent employees - FTEs), you can purchase qualifying coverage for your employees through Massachusetts Health Connector Business Express, the state’s SHOP (Small Business Health Option Program) exchange, or through a private broker or insurance agent. However, you may qualify for tax credits worth up to 50% of your premium costs if you use the state exchange. Beginning in 2016, SHOP will be open to employers with up to 100 FTEs. Under the Employer Shared Responsibility provision of ACA, beginning in 2015, all employers with 50 or more FTEs must offer employees at least one plan that is ACA-compliant or face fines of $2,000 per employee.

ACA Standardized Benefits
Plans offered by private insurers may offer additional benefits and individual states may require additional benefits, but all qualifying plans must offer these 10 standardized essential benefits:

  • Ambulatory patient service
  • Emergency services
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Mental health and substance use disorder services including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Preventive and wellness and chronic disease management for adults and children
  • Pediatric service, including oral and vision care
Lifetime dollar limits on these essential health benefits have been eliminated.

Massachusetts Additional Mandated Benefits
Massachusetts currently mandates that the following benefits, which exceed ACA requirements, must be provided or offered by private providers authorized to sell health insurance within the state:

  • Bone marrow transplants - for treatment of breast cancer - for individual, small and large group plans
  • Cardiac rehabilitation - for individual, small and large group plans
  • Clinical trials - for individual, small and large group plans
  • Congenital anomaly - cleft lip/palate - for individual, small and large group plans
  • Diabetes care management - services and supplies - for individual, small and large group plans
  • Early intervention services - for individual, small and large group plans
  • Emergency transportation/ambulance coverage - for individual, small and large group plans
  • Hearing aids - for individual, small and large group plans
  • Home health care services - for individual, small and large group plans
  • Hormone replacement therapy - for individual, small and large group plans
  • Hospice care - for individual, small and large group plans
  • Human leukocyte antigen testing - for individual, small and large group plans
  • Hypodermic syringes or needles - for individual, small and large group plans
  • Infertility treatment - for individual, small and large group plans
  • Off label prescription drugs - to treat cancer, HIV/AIDS - for individual, small and large group plans
  • Outpatient rehabilitation services - speech, hearing and language disorders - for individual, small and large group plans

Massachusetts Available Standardized Plans
To help you more easily compare costs and benefits, ACA designates that all qualifying plans be one of four metals: Bronze, Silver, Gold and Platinum. Each is based on the average amount of healthcare costs the plan will cover shown as a percentage of what is covered by your insurance company and what is paid for by you. All insurers participating in the federal or a state healthcare exchange must offer , at minimum, Silver and Gold plans. All metal plans have a shared maximum out-of-pocket amount that you can be charged in any calendar year.

Metal PlanInsurer PaysYou Pay
Bronze60%40%
Silver70%30%
Gold80%20%
Platinum90%10%

In addition, if you are under 30 or meet the criteria for a hardship exemption, you can purchase a catastrophic plan that is compliant with ACA requirements.

Carriers may also offer non-standardized products to consumers.

Premiums
Premiums charged for any of the qualifying metal plans may be based on:

  • Your age
  • Tobacco use
  • Where you live - determined by rating area
  • The number of family members enrolling with you

Guaranteed Issue
Under ACA, no one can be denied coverage or charged significantly higher premiums because of past health history (pre-existing conditions) or gender. There can be no look-back or waiting periods imposed. Policies are effective on issue. All coverage is renewable, if you choose to renew it. Plans can only be canceled for non-payment of premiums or fraud. The guaranteed issue provision applies to all non-grandfathered plans.

ACA Financial Assistance
You may qualify for financial assistance in the form of tax credits to help with monthly premiums and subsidies to help with out-of-pocket costs.

  • Tax credits can be applied to any of the four metal plans to lower your monthly premiums. They are paid directly to your insurance provider by the federal government. Your tax credit is based on your estimated income for the calendar year, in advance of filing your federal return. Note that if your actual income exceeds the eligibility limit, you will have to reimburse the government for the difference. Tax credits are only available to Massachusetts residents who purchase coverage from Massachusetts Health Connector.
  • Subsidies to help Massachusetts residents with out-of-pocket expenses such as copayments are only available for Silver plans purchased through Massachusetts Health Connector and are only offered to those who earn up to 250% of the federal poverty level.

Provider Options
The following types of health insurance plans are available in Massachusetts for individuals and families. They may be purchased through private providers or providers participating in Massachusetts through the state exchange.

  • Preferred Provider Organizations (PPOs)
    You have access to a network of healthcare providers participating in your selected PPO. You do not have to select a Primary Care Physician or obtain a referral to see any in-network provider. Some PPOs may require that you meet a deductible before their portion of the coverage begins.
  • Health Maintenance Organizations (HMOs)
    Most HMOs require you to select a Primary Care Physician to coordinate your healthcare and provide referrals to specialists. HMOs typically charge a fixed copayment for each doctor visit and other care provided. Depending on the HMO, there may be a low deductible or no deductible in addition to the copayments. All services must be obtained through the HMO's network, unless otherwise stated in your plan.
  • High-Deductible Health Plans with Health Savings Accounts (HDHP w/HSAs)
    These plans give you more control over your out-of-pocket expenses by offering lower monthly premiums with higher deductibles. They are typically combined with HSAs that allow you to set aside interest-earning pretax funds (through your employer’s payroll deduction) or tax-deductible funds you deposit in a private account. These funds can be drawn on to cover your healthcare costs. Any interest accrued is tax-deferred and any unused funds can roll over from year to year. See your tax advisor for information specific to your situation.
  • Flexible Spending Accounts (FSAs)
    ACA provisions allow you to continue to make tax-free contributions up to $2,500 per year to an FSA. These can be used for out-of-pocket healthcare expenses not covered by your insurance plan. This includes many over-the-counter (OTC) preparations, devices and equipment as allowed by law. However, you will need to obtain a prescription for OTC items and submit an itemized receipt to qualify for the tax deduction.

Massachusetts Healthcare Resources
Low- and no-cost healthcare for Massachusetts residents include:

Massachusetts Regulating Agencies and Insurance Information Resources

Massachusetts Division of Insurance
http://www.mass.gov/doi
617-521-7794
1000 Washington Street, Suite 810, Boston, MA 02118-6200
P.O. Box 517, Frankfort, Massachusetts 40602-0517

Insurance Information Institute
http://www.iii.org
212-346-5000
110 William Street, New York, NY 10038

Massachusetts Health Insurance Exchange
https://www.mahealthconnector.org/
1-877-623-6765
Find local in person enrollment assistance

Healthcare Insurance for Massachusetts Small Businesses
http://bettermahealthconnector.org/learn/small-businesses
877-623-6765

Fast Facts About ObamaCare
http://obamacarefacts.com