1 Commonwealth of Massachusetts Health Plans for Individuals and Small Groups in Massachusetts Consumer Information Guide 1
2 If you live in Massachusetts and you are age 18 or over, you must have a health plan. This health plan must be Minimum Creditable Coverage. These are the essential benefits that you need to be considered insured and avoid state tax penalties. Health insurance companies licensed in Massachusetts must let consumers know if their plans meet these standards. Look for a notice on the front of your plan documents. If you have a group plan through your employer, you may also contact your plan administrator, otherwise contact your plan directly. You will need to show that you have Minimum Creditable Coverage when you file your state income tax return each year. If you do not have a health plan, you may have a penalty on your state income tax of up to half the cost of the least expensive plan available to you for each month that you do not have a health plan. See the Commonwealth of Massachusetts Department of Revenue website for guidelines on tax penalties. This brochure is designed to explain access to individual and small group health plans. You may have access to some other type of health plan besides the ones described. Am I Eligible for Individual or Small Group Coverage? Your eligibility to enroll in a health plan in the individual & small group market depends on whether you are an individual seeking coverage or you are an employee of a small business. Individuals You and your dependants may enroll in an individual health plan if you are a resident of Massachusetts and you are not offered an employment-based health plan that meets Minimum Creditable Coverage standards. Employees You and your dependents may enroll in a health plan for small groups if you are an eligible employee of a small group employer that offers this coverage. This includes an owner, a sole-proprietor or a partner of a partnership. Health Coverage Step-by-Step Now that you know that you need some sort of health plan that meets the Minimum Creditable Coverage standards, you now must go through a threestep process: 1) Eligibility Your first step is to determine if you are eligible for an individual or small group health plan, or some other type of plan 2) Find a Health Plan Once you determine your eligibility, you must then select a health plan that is right for you 3) Enrollment Finally, you must determine when you are allowed to enroll in your new health plan Dependents If there is a family health plan available to you, the insurer will describe the dependents that can be included on the plan. This will generally include a spouse and children, but may include other dependents, such as a domestic partner. Massachusetts and federal law allows you to include your child who is under 26 years of age on a family plan. The enrollment form will ask for information on the eligible dependents that you want to include.
3 I Cannot Get Health Coverage Through an Employer. What is Available to Me? Whether it is because you lost your job or your employer does not offer health coverage, if you can t get health coverage through an employer, you may be able to buy a health plan directly from an insurance company or through the Health Connector. Through the Health Connector The Health Connector is an independent state authority that can help you purchase a health plan. They offer three types of health plans: Commonwealth Care You may be able to join a Commonwealth Care plan if your family income is at 300% or less than the federal poverty level (FPL). Depending on your income, you may need to pay some of the monthly premium for the plan, or the state may cover the full cost. Commonwealth Choice For more information on Health Connector plans: MAhealthconnector.org MA-ENROLL Any eligible individual can enroll in Commonwealth Choice. You have the choice of several health plans offered by different insurance companies. All plans offered through Commonwealth Choice have the Connector Seal of Approval. Young Adult Health Plan (YAP) The Health Connector s Commonwealth Choice program includes Young Adult Health Plans (YAP)from several insurers. If you are between the ages of and do not have access to a health plan through an employer, you may be eligible for one of these plans. For purposes of a YAP, employer subsidized coverage means that your employer pays at least 33% of the cost of your insurance. All plans offered through Commonwealth Choice have the Connector Seal of Approval. Connector Seal of Approval The Health Connector asks insurers to submit a range of plans to meet the budgets and health needs of different consumers. Plans that meet the Health Connector s standards for quality and value receive its seal of approval. Directly from a Health Insurance Company Several insurance companies in Massachusetts offer health plans directly to individuals. You can contact the insurer to learn more about the health plans offered, and ask for an application to join the plan. Always check with the Division of Insurance to make sure that a health insurer is licensed. Finding an Insurance Company If you want to find a health insurance company on your own but don t know where to start, you can go to the Division of Insurance website This list shows the names and phone numbers of insurance companies that offer health plans to individuals.
4 I am the Owner of a Small Business. What is Available to Me? You can buy a health plan for your small business through the Health Connector or directly from an insurance company. Keep in mind that a small business includes a sole-proprietorship where there is only one employee in the group. Through the Health Connector The Health Connector offers the Business Express program to small businesses (those with 1-50 employees). With Business Express you have the choice of several health plans offered by different insurance companies. All plans offered through Business Express have the Health Connector s Seal of Approval and meet the state s minimum creditable coverage standards. All of the health plans that are offered to eligible individuals must also be offered to small groups. However, the insurer may have more requirements for a small group. The small group may need to have a certain percentage of eligible employees join the plan. Also, the small group may need to go through an intermediary if it has fewer than 6 eligible employees. Through an Insurance Agent An insurance agent may also assist you with selecting and enrolling in a health plan. A Massachusetts insurance agent must be licensed by the Commonwealth of Massachusetts in order to sell, solicit or negotiate insurance. Your premiums will not be higher if you buy a health plan through a licensed agent. For more information on Health Connector plans: MAhealthconnector.org MA-ENROLL Directly from an Insurance Company Several insurance companies in Massachusetts offer health plans directly to small groups. You can contact the company to learn more about the health plans they offer. This list shows the names and phone numbers of insurers that offer health plans to small groups. Always check with the Division of Insurance to make sure that a health insurer is licensed. Intermediaries An intermediary handles enrollment and collects premiums for the insurance company. See the list (link to list) of insurance companies to find the ones that require the use of an intermediary.
5 When Can I Enroll? The rules regarding when you can enroll in a health plan differ for individuals and small groups. Individual Health Plans Eligible Individual with Prior Coverage in a Health Plan If you had prior coverage in a health plan, you may enroll in a new health plan at any time, but you must apply within 63 days of the end of your prior coverage. You must also meet one of the following conditions: You had group health coverage that was in effect for a total of 18 months or more, and was not terminated due to fraud or non-payment of premium on your part, or You were dis-enrolled from your individual health plan that was HIPAA creditable coverage because you lost your dependent status, or You were disenrolled from your individual health plan that was HIPAA creditable coverage because the carrier closed the plan, or You moved and your individual health plan that was HIPAA creditable coverage was terminated because you are now outside the health plan s service area, or You lost eligibility for a qualified student health plan. Eligible Individual without Prior Coverage in a Health Plan If you did not have prior coverage in a health plan, you will have to wait for an open enrollment period. An eligible individual without this prior coverage may only apply to purchase an individual health plan during the annual open enrollment period - July 1 and August 15 every year. When you submit an application during the open enrollment period, the insurer must make the health plan effective within 30 days of receipt of the completed, accepted application. HIPAA Not Just a Privacy Law Most people who have heard of the the Health Insurance Portability and Accountability Act (HIPAA) think of it as a law that protects the privacy of medical information. But HIPAA also gives people the to ability change jobs without losing health coverage. HIPAA: Limits a health plan s ability to exclude coverage for preexisting conditions Provides additional opportunities for you to enroll in a group health plan if you lose other coverage or experience certain life events (e.g. marriage, birth, divorce, death of a spouse) Prohibits discrimination due to certain health factors Guarantees certain individuals access to individual health plan Under HIPAA, creditable coverage is defined as health coverage of an individual under a specific list of health plans with no lapse of coverage of more than 63 days Group Health Plans If you are an eligible employee of an employer group you may enroll during the employer s open enrollment period. As this will vary depending on the employer, you should see your employer for information on the open enrollment dates.
6 When Can I Add a Dependent to My Health Plan? Individual Health Plans If you are enrolled in an individual health plan, your insurer must enroll an eligible dependent (see the description of dependents on page 2) into your health plan within 30 days of any of the following events that qualify the dependent for coverage: Marriage (and establishment of domestic partnership, if available under the terms of the policy), or Birth of a child, or Adoption of a child or placement of that child for adoption; or The dependent s loss of creditable coverage from another group or government plan, or Upon court order. How Do They Come Up with My Rate? Your insurance company may set premiums based on the benefits of the plan, where you live, the coverage type - i.e. family or single - and the group size. The insurer may also base the premium on your age, your industry, the participation-rate for your group (does not apply to individuals), participation in wellness programs and tobacco use. You can call the Health Connector or any of the insurance companies on the list at the end of this guide to learn more about the health plans offered and the premiums you would pay. If you want to add a dependent and you do not have one of the qualifying events listed above, you can add the dependent during the open enrollment period for individual health plans, which is from July 1 through August 15 each year. Group Health Plans If you are enrolled in a group health plan, your employer or plan sponsor will tell you what the qualifying events are for adding a dependent. HIPAA rules require that you notify your plan administrator within 30 days of a qualifying event. If you want to add a dependent and you don t have one of the qualifying events, you can add the dependent during the employer s annual open enrollment period.
7 Can My Insurance Application Be Denied Because of My or My Dependent s Medical History? No. Insurers cannot deny coverage due to your: Age Occupation Actual or expected health condition Claims experience, the length of your coverage Health Waiting Periods This is a period of time immediately after the effective date of your health plan. During this time the insurer will not pay for any services except emergency services. If you apply for the new health plan within 63 days of the end of your prior health plan, the insurer must waive or reduce the time of the pre-existing condition limit. These limits and waiting periods do not apply to children up to age 19. Insurers may deny coverage if you: Live outside their service area Have not paid the plan premiums Are seeking to replace an employment-based health plan for which you are eligible and that is equivalent to minimum creditable coverage Give false information on your application or claim forms While insurers cannot deny an application because of issues related to medical history, health plans may have pre-existing condition limits or waiting periods. Ask your insurer if they have any of the following: Pre-existing Condition Limitations This means that for up to the first six months of your coverage, the insurer will not pay for services related to a health condition that you had before you joined the plan. Insurers can only look at any diagnosis or treatment in the six months before you joined the plan. Genetic information does not count as a pre-existing condition if there is no diagnosis of a condition related to that information. Pregnancy is not a pre-existing condition.
8 What is Covered in My Health Plan? A health plan will usually cover some or all of the cost of emergency care; hospital stays and doctor visits; preventive care; and sometimes prescription drugs. Mandatory Benefits All insured health plans must include certain benefits that are mandated by Massachusetts law. Self-funded health plans do not have to offer statemandated benefits. Your employer can tell you if your health plan is selffunded. Minimum Creditable Coverage Minimum Creditable Coverage is the set of essential benefits that your health plan must include in order for you to avoid state tax penalties. Health insurance companies licensed in Massachusetts must let consumers know if their plans meet these standards. Look for a notice on the front of your plan documents. People enrolled in out-of-state plans or self-funded health plans should contact their employer or insurer. Prescription Drugs Cost Sharing You may need to pay for a share of the cost of care through deductibles, coinsurance or co-payments. The exact amount of cost sharing varies from plan to plan, but most plans have some variation of the following: Co-payments Deductibles A fixed dollar amount that you pay directly to a doctor, hospital or pharmacy at the time you receive health care service. Example: You pay a copayment for a primary care visit of $20 or $100 for an emergency room visit, and your health plan pays the rest. The amount you pay before the plan starts to pay for a covered service. Example: You pay a $1,000 deductible toward your health care services each year before the plan pays any benefits. In order to satisfy the requirements of Minimum Creditable Coverage, individuals must have coverage that includes prescription drugs. But not all plans include drug coverage. Read your plan carefully to see what it includes. Co-insurance A percent of the allowed charge that you pay for a covered service. Example: You pay 20% of the cost of a covered office visit and the plan pays the rest.
9 Types of Health Plans Because there are many different types of health plans, you should be sure to look for the one that fits your needs. Here are some of the types of plans offered in Massachusetts: Health Maintenance Organization Plans (HMO) HMOs cover hospital, medical and preventive care. You are only covered if you get your care from the HMO s network of providers (except in a case of emergency). Many HMOs require Primary Care Physicians and make use of referrals. With most HMOs you pay a copayment for each covered service. For example, you pay $10 for an office visit and the HMO pays the rest of the cost. Preferred Provider Organization Plans (PPO) PPOs usually cover hospital, medical and preventive care. These plans have a network of preferred providers that you can use, but they also cover services for out-of-network providers. PPOs will pay more of the cost if you use a provider that is in the network. Example: the plan pays 100% of a service for a network provider but 80% for an out-of-network provider. Major Medical Plans/ Indemnity Plans Major medical plans come in a variety of plan designs. They generally cover some hospital and medical expenses. Some may also cover preventive care and office visits but this coverage may be limited. Some have high deductibles and some have limits on certain benefits. They may also have coinsurance or set dollar amounts payable for certain benefits. Example: the plan has an annual deductible of $5,000, pays 80% of your hospital stay and has an annual limit of $500 for office visits. Is There Any Assistance to Help Me Pay for Health Coverage? Massachusetts has several programs that may help you pay for a health plan. MassHealth MassHealth is a comprehensive health insurance program and premium assistance program for parents, children, senior citizens, and persons who are disabled or unemployed. Call to learn more or visit mass.gov/masshealth. Commonwealth Care Commonwealth Care is a state subsidized insurance program for those who earn 300% of the federal poverty level or less. The Health Connector manages Commonwealth Care. It offers a choice of plans. Call MA-ENROLL or (TTY) or visit MAhealthconnector.org for to learn more and to get an application. Children s Medical Security Plan Children s Medical Security Plan is a limited health insurance program for children that provides primary and preventive health care. Call or visit to learn more. Medical Security Plan Medical Security Plan is a state subsidized health insurance plan for people who are receiving unemployment insurance benefits. Call or visit mass.gov/dua to learn more. Insurance Partnership Program The Insurance Partnership Program is a state program for small group plans that subsidizes health insurance premiums for the employer and its employees. Call or visit to learn more and to get an application.
10 Whom Should I Call for Additional Information? If you have general questions about plan options, allowable pricing practices, or health insurance laws, call the Division of Insurance Consumer Services Section at (617) To get a list of health plans offered in Massachusetts, go to Division website, If you think that your health plan has not complied with a law, you can call the Bureau of Managed Care at , send a fax to or send an to The Division of Insurance does not sell, recommend, promote, or endorse any insurance product, company, or agent. The information in this guide is meant to help you make informed purchasing decisions. Every effort has been made to ensure the accuracy of this information; however, some of the information may be subject to change. This guide was produced as a public-private collaboration to help consumer understand how to navigate the individual and small group health insurance market. The following organizations contributed to the creation of this material: Massachusetts Division of Insurance Massachusetts Attorney General s Office Massachusetts Department of Public Health The Health Connector Health Care for All Health Law Advocates
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