Massachusetts insurance law & regulations
Massachusetts is one of two states that has an individual health insurance mandate law for 2019.
News that affects your health insurance and planning
February 28, 2020 – Massachusetts’ Attorney General Maura Healey announced a legal settlement with multiple health insurance companies charged with violating the federal mental health parity law. The companies are: Harvard Pilgrim Health Care, United Behavioral Health, Optum, Fallon Community Health Plan, Beacon Health Strategies, Allways Health Partners, Blue Cross Blue Shield of Massachusetts and Tufts Health Plan. The companies agreed to change how they establish reimbursement rates and to limit some prior authorization requirements for behavioral health care.
March 23, 2019 – Healthy food prescriptions could generate substantial health gains and be highly cost-effective, according to an innovative study published this week in PLOS Medicine by Yujin Lee and Dariush Mozaffarian of the Friedman School of Nutrition Science and Policy at Tufts University, Massachusetts. The authors point out that healthcare spending continues to increase dramatically, with diet-related conditions being a major driver. Fruit and vegetable prescriptions and other incentives for healthier eating have been implemented and proposed in small scale within healthcare systems but not at a wider scale. Thus, the health impacts, costs, and cost-effectiveness of healthy food prescriptions in healthcare are not well established.The authors introduce the possibility of expanding this strategy through through more Massachusetts residents enrolled in Medicare and Medicaid. The recently passed 2018 Farm Bill includes $25 million Produce Prescription Program which will provide pilot funding for such pilot projects over the next 5 years.
March 3, 2019 – Massachusetts still leads the nation in universal health care; for better or worse. This editorial sums it up: https://www.timesfreepress.com/news/opinion/columns/story/2019/mar/03/cleaveland-universal-health-insurance-massach/489684/
The history of health care planning in Massachusetts (Information is outdated and links may be expired)
2/11/ 2014 Professional support for any health care reform issue is available free of charge through an arrangement with OnlineNavigator. All online inquiries are handled personally by Tony Novak, CPA. Online support is available through a number of popular social media channels including Facebook and Google+ as well as e-mail. Telephone support for insurance enrollment is available through Members Insurance Exchange at (800) 609-0683.
10/9/2013 Partners Health Care, the state’s largest hospital system, says that it will likely meet the goal of keeping medical care cost increases below the state benchmark of 3.6 percent this year.
7/26/2013 Affordable Smart Term Life Insurance is now available to most Massachusetts residents from age 20 through 60 directly online with no physical exam, agent appointment or telephone verification. Most policies are issued on the same day with coverage amounts of $25,000 up to $350,000. The level premium life insurance is available for terms of 10, 15, 20 and 30 years. Sample rates for $150,000 coverage for a preferred risk male age 30, non-tobacco $30.85 per month; tobacco user $49.55 per month. A preferred risk female age 30 non-tobacco user would be $26.49 per month and a tobacco user would be $40.96 per month. Rates are higher for older applicants and lower health risks as described online. Pricing is based on input you provide about your medical history but, unlike most other life insurers, does not consider family medical history. Coverage is issued by innovative National Life Group, rated “A” by A.M. Best Company for 2013.
3/11/2013 This page was updated to include a link to the insurance plan that will be used to determine specific “essential health benefits” for insurance that qualified for 2014 federal tax purposes. Also, a link to additional covered benefits required by state law. Non-qualified insurance is likely to continue to be available at a lower cost that does not include these benefits nor qualify for federal tax purposes.
12/14/2012 Massachusetts is one of a minority of states that will run a health insurance exchange for individuals and small businesses that is not managed by the federal government. Consumer advocates who once viewed a state-run exchange as a positive are growing concerned that the state may not be fully committed to implementing all of the funding and features expected to be part of the federal health insurance exchanges that are expected to open in the fall of 2013.
6/27/2012 The state announced a legal settlement of $1 million fine against Aetna for selling low cost health insurance to students that does not meet the state’s minimum coverage requirements. Aetna is the dominant provider of student health insurance nationwide. Students generally prefer lower cost policies with lower benefit limits but these policies are not legal in Massachusetts and no law current exists to allow Massachusetts students to purchase insurance that is legally available on other states.
6/25/2012 CBS News issued a negative report yesterday on the results of Massachusetts effort to curb increases in health care spending. The report said that since the implementation of health reform the state’s overall health spending has risen from 36 to 43% of the state budget, and Massachusetts spends more per person on healthcare than any other state. Spending on health care is now reported to be $9,278 for every person in the state. The increases are presumed to be attributable to the state’s health reform law that preceded national health reform. The state’s response is to refuse to allow high premium rate increases and therefore force commercial insurance carriers to deny claims for increased amounts of coverage. This will likely result in increased litigation costs that will put additional inflationary pressure on premium rates.
2/1/2012 The Center for Consumer Information and Insurance Oversight, a division of the Center for Medicare and Medicaid Services (CMS)reported that as of June 30, 2011 Tufts Associated HMO, Blue Cross Blue Shield of Mass HMO Blue and Harvard Pilgrim Health Care are the state’s largest health insurance providers and as such, earn the right to set the benchmark for the development of the state’s essential benefit plans to debut in 2014 under health reform law.
1/30/2012 State legislators are scheduled to begin debate on the state’s soaring health costs stemming from the state’s experiment with universal health care. Today The Boston Globe reported on the impact of cost-controlled health coverage that are used by 20% of the state’s residents. The paper reports “The state’s four largest health insurers – Blue Cross Blue Shield, Harvard Pilgrim Health Care, Tufts Health Plan, and Fallon Community Health Plan – now have more than 1 million members in employer-sponsored health plans that put doctors at risk of losing money if they exceed the budget for their patients’ care, they said. Providers can earn extra profit if they spend less than budgeted”. Another 150,000 Medicare and Medicaid patients are covered under the cost-controlled plans. Tufts reports that 70% of its HMO members are now covered under budgeted spending plans that appear to be moving in opposition to federal health reform laws that require unlimited maximum spending caps. While this may be the brightest story in the state’s reform program, nobody is actually sure whether the program is actually saving any money. While last year’s spending came in 2.5% below budget, this result is more likely a reflection of impact of the recession rather than the impact of the health insurance program. The health plans still raised premium rates again by an average of 2.3% this year despite individual members’ trend toward postponing health care spending due to the slow economy. The Globe quotes Blue Cross Blue Shield chief executive Andrew Dreyfus stating what is already obvious to all: “We still have a lot of work to do. Health care is still very expensive and it’s still a significant burden on employers, families, and government.”
1/19/2012 With just under two year remaining until final individual health insurance reform laws take effect, Massachusetts is one of only five states that does not have a short term medical insurance plan available to bridge the gap until affordable basic health insurance becomes available to everyone. Short term medical insurance is popular basic coverage because it is exempt from the restrictions of health reform law and therefore priced less than half of the rate of a plan that includes all state and federally mandated coverage. The lack of short term coverage in the state has boosted medical insurance tourism among those who need immediate coverage for 2012. A policy purchased while residing outside the state provides valid coverage nationwide including within Massachusetts.
10/12/2011 Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, will remain a nonprofit public charity after examining whether it should seek a different legal status given its extensive business operations.
9/20/2011 US Fire Insurance Company halted enrollments in its popular supplemental Core Health Insurance due to the demands of increased marketing regulation in the Commonwealth.
7/27/2011 Parents are reminded that the children’s’ health insurance open enrollment period ends on Monday August 15 so applications should be submitted online before that date.
6/28/2011 UMass students must now pay 15% of the cost of their medical care not received through the campus health care facility up to a maximum of $5,000 per year under revisions to the student insurance plan. The University’s student accident and sickness insurance plan is offered through a commercial broker by Harvard Pilgrim or Aetna, depending on the campus location. The cost is approximately $1,200 per semester; about twice the average price of student health plans in other states. The university also requires students to enroll in a separate supplemental insurance, bulled with the tuition, for on-campus health care services. The new co-pay requirement was added because of escalating medical costs and high utilization triggered by Massachusetts health insurance law but are typical of student health plans in most other states. The UMass primary student health insurance may be waived if the student has equal coverage through a parent’s health plan but not all employer-provided health plans meet the University’s requirements. While most colleges require students to carry health insurance, out-of-state students and their families may be caught by surprise by the higher cost and unique far-reaching effects of the state’s health insurance experiment. The supplemental accident plans like Smart Accident, Value 24 Hour Accident and Value Emergency Room listed above can be used to reduce the financial impact of unexpected medical costs.
6/3/2011 As part of its process to prepare it’s 2011 Health Care cost trends report, this week the Massachusetts Department of Health and Human Services sent a letter to its health insurers like Celtic are Health Plan of Massachusetts for input into troubling cost trends.
Among the findings in the previous report, the state found:
Small businesses are paying more for premiums and have experienced sharper growth in rates than mid-size and large employers. 2010 experienced the largest increase in recent years.
Overall enrollment declined in all fully-insured group sectors but increased in the individual and self-insured market sectors.
Deductibles and out-of-pocket costs for policyholders grew substantially, almost doubling over the past three years.
The average size of insured small and mid-size groups decreased, while the average size of large groups and self-insured groups was relatively stable.
The individual sector was significantly older on average than the group sectors, covering relatively few children aged 0 to 19 and relatively more adults aged 60 to 64, despite the inclusion of Young Adult Plans in the individual sector.
Small groups paid 140 percent of what large groups did towards non-medical spending.
These problematic trends indicate to us that the state will likely make changes to its current insurance laws based on any new findings and that the demand for individual supplemental insurance on a voluntary basis will continue to grow. We cover these plans and related news items on the Massachusetts page of the Freedom Benefits insurance exchange.
2/17/2011 The University of Massachusetts Medical School was granted more than $31 million by the U.S. Department of Health and Human Services to develop technology that will allow individuals and small businesses in Connecticut, Maine, Massachusetts, Rhode Island, and Vermont to shop for health plans consistent with national reform goals for 2014.
2/16/2011 The Massachusetts Division of Insurance approved 2011 premium rate increases for the nine health insurance plans that make up The Connector. The rate increases range from about 1/4% to 9.9% and become effective April 1, 2011 for all new and existing primary health insurance. The supplemental, international and executive insurance plans listed here on Freedom Benefits insurance exchange are not affected by the rate increase. While the price increases are lower than in past years, initial reaction was unfavorable because some residents are already struggling with the cost of mandatory health insurance. The governor’s office refused to grant increases of 10% or more despite a number of threatened or ongoing lawsuits against the state from the insurance companies. Separately, last month the state increased the 2011 penalties for those who do not carry health insurance. Listed in order of amount of rate increases, the increase breaks down as:
Blue Cross Blue Shield (non-HMO) 1.4%
Health New England 2.8%
Neighborhood Health Plan 8%
Fallon Community Health Plan 8.4%
Tufts Health Plan 9.0%
Blue Cross Blue Shield HMO 9.2%
United Healthcare of New England 9.9%
2/11/2011 Freedom Benefits plans to expand online resources for low income residents as the Commonwealth of Massachusetts phases in cutbacks in Medicaid and subsidized health plan benefits later this year. Although our strategic plan was modified earlier this month to move away from services for lower income customers, we believe that addition of online resources is the best way to deflect inquiries that could otherwise clog the free OnlineNavigator support system that offers advice to consumers with health plan enrollment questions.
2/8/2011 A spokesman for the Health Connector said that a ruling last week by a federal judge in Florida that health reform is unconstitutional won’t affect the 2006 Massachusetts mandate that all residents have health insurance. Senate President Therese Murray agreed, saying that the ruling centers on issues of interstate commerce and the scope of federal authority to the states, and those issues are not applicable to the Massachusetts law.
2/7/2011 The state’s pre-existing condition insurance plan (PCIP) monthly premium rates (per person):
PCIP will cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available for you, beginning on your coverage effective date, even if it’s to treat a pre-existing condition – there are no waiting periods. PCIP applicants who are approved to participate in PCIP can choose from three plan options, with different levels of premiums, calendar year deductibles, prescription deductibles and prescription copays. The HSA Option provides an opportunity to open a Health Savings Account, a tax-exempt account where you can deposit funds for eligible medical expenses. Each of the three PCIP plan options provides preventive care (paid at 100%, with no deductible) when you see an in-network doctor and the doctor indicates preventive diagnosis. Included are annual physicals, flu shots, routine mammograms and cancer screenings. For other care, you will pay a deductible before PCIP pays for your health care and prescriptions. After you pay the deductible, you will pay 20% of medical costs in-network. The maximum you will pay out-of-pocket for covered services in a calendar year is $5,950 in-network/$7,000 out-of-network. There is no lifetime maximum or cap on the amount the plan pays for your care. If you apply for PCIP coverage on the government Web site, you will be billed for the premium once your application is approved. You will need to send in your payment in order for your coverage to be effective. Please do not send in the premium before you are billed. Note that your premium may increase if you age into a higher rate tier, or if PCIP adjusts its premiums to any changes in the commercial market.
1/1/2011 Tax penalties for being uninsured in 2011 – The tax penalty for individuals between the ages of 18 and 26 with incomes above $32,496 who do not have health insurance rises to $72 per month in 2011. For individuals 27 or older with income above $32,496 the penalty increases to $101 per month. Penalties are doubled for two parent families in which both are uninsured. Penalties are lower for uninsured individuals up to $32,496 and families with incomes up to $66,156 for a family of four. Penalties for those in this group range from $19 to $58 per month. Penalties in each of these categories are far less than the public cost to provide medical care for this uninsured population. Individuals with incomes less than $16,248 per year and a families with incomes less than $33,084 (based on a family of four) are exempt from the tax penalty.
12/16/2010 Massachusetts Division of Insurance officials met representatives of 44 other states and numerous employees of the federal Health and Human Services Department in Washington DC this week for a two-day working meeting to discuss the next steps in establish a government-run health insurance exchange under the American Health Benefit Exchange Model Act. Their attendance at this meeting was paid for by a $1 million federal grant awarded by HHS in September to the state for research how to set up an insurance exchange. Two states (Alaska and Minnesota) declined to participate, saying that it was a waste of taxpayer money. Four other states (not identified in press reports) that received federal grants did not send representatives to the meeting. Attendees included representatives of 16 states that are suing the federal government in an attempt to overturn the federal health reform law; specifically the requirement that forces individuals to buy health insurance on the insurance exchange or pay a hefty tax fine.
In its initial federal grant request for the insurance exchange project, Massachusetts said that it would: 1) Identify current Health Connector programs, policies, and practices in need of modification given new national requirements for Exchanges, 2) Identify a strategic and operational plan and implementation timeline, 3) Conduct research to anticipate changes in sources of insurance coverage before and after 2014, and the size and characteristics of the population served by the State Exchange, 4) Engage stakeholders in the discussion of Exchange-related issues, 5) Collaborate with MassHealth to identify and recommend changes to the existing information technology and operational infrastructure needed to comply with new requirements for Exchange eligibility determinations in 2014, 6) Review current cash flow structure and identify changes that may be necessary under national reform, 7) Review current products offered through the Connector and how they align with specifications for plan design under national reform, and 8) Examine statutory and regulatory actions to identify potential needed changes, such as minimum essential coverage requirements, definitions of affordability and exemptions from the individual mandate.
The meeting reportedly did not address the role of the commercial health insurance exchanges on the implementation of new competing government systems. The model act does not address inter-state insurance exchange proposals nor insurance sales across state lines. Federal officials admitted that they may not be able to provide further guidance until 2012. Meanwhile, most states are motivated to continue to meet requirements to obtain additional funding promised by the federal government for the establishment of insurance exchange by 2014. Freedom Benefits has previously voiced the opinion that the huge amount of money being spent to set up alternate insurance sales system technologies could be better used providing health benefits to the public. We proposed on the Universal Health Insurance blog that adequate commercial insurance sales systems are already in place that could be modified in a public/private partnership to make health insurance more affordable.
12/1/2010 The three year open enrollment period for the Group Insurance Commission health plan for government workers is now ended without a single municipality joining the low cost insurance plan. State officials admit they must go back to the drawing board for new solutions. We presume that an increasing number of municipal employees are finding coverage through the individual health insurance exchange.
5/14/2010 Diabetes Coverage: A new resource to help find health insurance for diabetics in Massachusetts is now available at Freedom Benefits.
4/20/2010 Six health insurance companies that were unable to offer policies that meets the state’s requirements have simply not issued rates for the month of April. This effectively stopped applicants from obtaining coverage. The companies appear now to be in a bind as the insurance commissioner threatened to levy significant fines if coverage is not offered to residents who wish to apply. Earlier in the month insurers lost a legal bid to offer higher premium rates than the state will allow. Our primary concern is that in other similar situations in other states the insurance companies simply stopped doing business in the state until the legislative restrictions are addressed. Maine residents currently have with fewer insurance choices than the residents in most other states. This latest move could further reduce consumer choices. Until this governmental battle is resolved, we suggest the “Value Access Guarantee” association benefit plan (not an insurance plan) or Core Health Insurance insured by United Sates Fire Insurance Company as the best available limited benefit insurance that is available on a guaranteed issue basis to Maine residents. Since this is limited benefit coverage, we suggest increasing the overall level of insurance by combining these insurance with one or more of the supplemental policies listed above. Supplemental polices pay defined cash benefits in addition to other coverage.
4/8/2010 As of today, only one individual health insurance company offers individual major medical insurance coverage on the Massachusetts health insurance exchange under the authorized premium rates. Some other insurance carriers have temporarily stopped issuing new policies because the state has not approved rates that are sufficiently higher than the claims that are expected to be paid.CeltiCare of Massachusetts is also the only company that has not joined in a lawsuit against the Commonwealth for blocking rate increases.
4/1/2010 Massachusetts residents face more significant obstacles finding insurance exchange than residents elsewhere in the U.S. following failed attempts by 2006 state legislation to provide universal health insurance. Those concerns are building as health insurance premiums remain unaffordable and thousands of additional Massachusetts residents previously excluded from the law must not obtain coverage. Meanwhile, total health care expenditures soared by about 50% and medical provider shortages now affect quality of care even for those who can afford the insurance and out-of-pocket expenses. Insurance companies have avoided this state’s stagnant and over-regulated market. Insurance companies are expected to announce additional pull-backs this month. Ironically, the state legislature may respond to this failed government regulation by passing even more restrictive legislation that could entirely convert the state insurance exchange into a single-payer system that would further accelerate their consumer problems. Unfortunately we see no relief for consumers under the state’s current political leadership. Eventually the state must return to a less regulated health care market with low cost options similar to those available through other states’ health insurance exchange.
12/23/2009 Massachusetts students fear higher health insurance costs