Massachusetts Health Insurance Guide
Massachusetts Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
Massachusetts provided the template for the federal Affordable Care Act (ACA). Since 2006, Massachusetts residents 18 and older have been required to obtain health insurance coverage that the state deems affordable for their income levels and that meet the minimal creditable coverage (MCC) standards set by the Commonwealth Connector (the state insurance exchange). Failure to comply can result in a penalty assessed on personal state income taxes. There is an appeal process for seeking waivers to the mandate. As a Massachusetts resident you can choose from health insurance plans provided to individuals and groups by private insurance carriers or through the Commonwealth Connector. Eligible individuals and families may also take advantage of low-cost and no-cost health insurance offered by Massachusetts State-funded programs, as well as government-sponsored programs such as Medicaid, COBRA and the Pre-Existing Conditions Insurance Plan (PCIP).
Massachusetts Guaranteed Issue PolicyMassachusetts is a guaranteed issue state with open enrollment periods for individuals. That means private insurers are required to sell health insurance to individuals. You cannot be turned down, asked to pay a higher premium or offered limited coverage because of a pre-existing condition (see Massachusetts and the Affordable Care Act below for other information regarding pre-existing conditions). All small group policies are guarantee issue.
Massachusetts Guaranteed Renewal PolicyMassachusetts is a guaranteed renewal state. While your insurance company has the right to increase the premiums on your individual health care policy based on age and other factors, they cannot cancel your policy as long as you pay your premiums, do not defraud the insurers, and in the case of some managed health programs, do not move out of the coverage area. If your Massachusetts health insurance is provided through an employer’s group plan, your coverage cannot be canceled or subject to higher premiums because of your health status or claims’ history.
Massachusetts and the Affordable Care Act of 2010
The Affordable Care Act (ACA) has no direct impact on individual state mandates, however it may have significant impact on some aspects of your health care. As of September 23, 2010:
- Insurers can no longer impose pre-existing condition exclusions on children under age 19. The ban includes both benefit limitations and outright denial of coverage. These protections apply to all types of insurance except individual policies that are grandfathered. Beginning in 2014, these protections will be extended to all ages.
- ACA eliminates the use of lifetime benefit caps on such essential services as ambulatory patient care, hospitalization, emergency services, chronic disease management, lab services, maternity and newborn care, preventive and wellness care, and prescription drugs.
- Health insurance providers must provide full coverage for preventive health care recommended by the Centers for Disease control including immunizations.
- New ACA rules make emergency services more accessible by prohibiting health plans and insurers from charging higher copayments or coinsurance for emergency services obtained out of a plan network.
- ACA allows children under age 26 to stay on their parents’ family policy or be added to it. Grandfathered group plans can limit this benefit to adult children who do not have any other offer of employment-based coverage.
A number of additional ACA mandates are scheduled to go into effect in 2014.
Massachusetts Mandated Health Benefits
Massachusetts laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Adopted children coverage under parent’s policy
- Blood Lead Poisoning
- Bone Marrow Transplants
- Cervical Cancer and HPV Screening
- Clinical Trials
- Continuation/employees coverage
- Diabetes Supplies
- Domestic partner coverage
- Emergency Services
- Hair Prostheses
- Handicapped and continuation/dependents under parent’s policy
- Home Health Care
- In Vitro Fertilization
- Maternity and Maternity Stays
- Mental Health
- Newborn children coverage under parent’s policy
- Prescription Drugs
- Prostate Cancer Screening
- Rehabilitation Services
- Well-Child Care
Private Health Care Options in MassachusettsIndividuals and small businesses in Massachusetts may chose from a variety of Health Maintenance Organizations (HMO); Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans.
- For Individuals and Families – There is no medical underwriting permitted and you may not be turned down because of current or past health conditions. Insurers who sell individual plans are required to offer standardized policies to all applicants. All options must offer comprehensive coverage. Insurers are allowed a 6-month look-back period and 6-month exclusionary period for pre-existing conditions if there is no proof of prior creditable coverage or a break in coverage greater than 63 days. 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. Eligible individuals may also choose from low-cost plans offered through the Commonwealth Connector (the state insurance exchange) or directly from private insurers.
- For Small Businesses (1 – 50 employees) – There is a maximum 6-month look-back period and a 6-month exclusionary period for pre-existing conditions for enrollees without prior creditable coverage. Pre-existing conditions are covered. Insurance must be offered by employers to any employee who works 35 or more hours per week. Types of insurance offered and the amount of employer contribution will vary based on the number of employees and other criteria. Employers may impose a waiting period. Group health insurance rates are community based. Cost to employer depend on group size, industry, location, family composition, the percentage of participating employees and age. Employers may also offer non-employer-sponsored plans through the Commonwealth Connector for part-time and other ineligible employees. Small businesses can also take advantage of premium assistance through the state’s Insurance Partnership.
Public Health Care Programs in Massachusetts
- MassHealth – comprehensive health insurance and premium assistance for eligible residents. www.ma.gov/masshealth
- Massachusetts Children’s Medical Security Plan (CMSP) – Comprehensive coverage for eligible resident children under age 19www.cmspkids.com
- The Insurance Partnership – Premium assistance for small employers with 50 or fewer eligible employees.www.insurancepartnership.org
- CommonWealth Care – Four plans providing levels of comprehensive benefits with copayments based on income.www.mahealthconnector.org
- Women-Infants-Children (WIC) – Nutrition education and supplemental food for eligible residents.www.mass.gov
- Breast Cervical Cancer Treatment Program (BCCTP) – Screening, diagnostic and treatment for eligible residents.www.massresouces.org
Regulating Agencies and Insurance Information ResourcesMassachusetts Division of Insurance
1000 Washington Street, Suite 810
Boston, Ma 02118-6200
(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.
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.
110 William Street
New York, NY 10038