Massachusetts Health Insurance Guide

Types of plans offered in Massachusetts include major medical health insurance coverage such as Personal Health Quotes, Family Health, and Group Health. Start your search for low-cost health insurance today!

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The state exchange is no longer available. If you are a resident of this state, you can purchase health insurance directly from an insurance company (get quotes here) or at www.healthcare.gov

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 HealthCare.gov, the federal exchange. If you are self-employed with no employees, you can also use the federal 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

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 SHOP (Small Business Health Option Program) at the federal 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 federal 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 Plan	Insurer Pays	You Pay
Bronze	60%	40%
Silver	70%	30%
Gold	80%	20%
Platinum	90%	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 Healthcare.gov.
Subsidies to help Massachusetts residents with out-of-pocket expenses such as copayments are only available for Silver plans purchased through Healthcare.gov 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 federal 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:

Breast & Cervical Cancer Screening – for low income women –http://www.mass.gov/eohhs/gov/departments/dph/programs/community-health/womens-health-network.html
Breast & Cervical Cancer Treatment Program – for eligible women –http://www.mass.gov/eohhs/gov/departments/masshealth/
Children & Youth with Special Health Care Needs –http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/children-and-youth-with-special-health-care-needs-program.html
Children’s Medical Security Plan – coverage for eligible children under 19 – http://www.mass.gov/eohhs/consumer/insurance/more-programs/childrens-medical-security-plan.html
Clinic List – free, low-cost and sliding scale clinics –http://www.needymeds.org/free_clinics.taf?_function=list&state=ma
Early Intervention – assistance for children with developmental delays to three –http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/early-intervention/
Health Safety Net – free care at community health centers and hospitals –http://www.mass.gov/eohhs/gov/departments/masshealth/
Healthy Start – free insurance for eligible pregnant women –http://www.mass.gov/eohhs/gov/departments/masshealth/
Mass HIV Drug Assistance Program –http://crine.org/hdap/
MassHealth – Massachusetts Medicaid – http://www.mass.gov/eohhs/gov/departments/masshealth/
Mini-COBRA – extended benefits program –http://www.mass.gov/portal/jobs-education/unemployment-assistance/health-retirement/
Statewide Head Injury Program – assistance to families with a member with traumatic brain injury – http://www.mass.gov/eohhs/gov/departments/masshealth/

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

Federal Healthcare Exchange
https://www.healthcare.gov
1-800-318-2596
Find local in person enrollment assistance

Healthcare Insurance for Massachusetts Small Businesses
https://betterhealthconnector.com/get-started/small-businesses
877-623-6765

Fast Facts About ObamaCare
http://obamacarefacts.com