Massachusetts is home to preppy vacation spots, some of our nation’s best universities, and the largest city in New England. Full of historical sites and architecture, Massachusetts was the site of many “firsts” in U.S. history as a result of colonization. Now it is a densely populated small state with several big cities, and a rocky coastline of beaches dotted with sailboats. It is also one of the few guaranteed issue states for health insurance. Massachusetts offers all of its residents a health plan either through an employer, a state plan, or a private health insurance company.
Insurance companies in Massachusetts include Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care and Fallon Community Health Plan. Most individuals are covered by Blue Cross, though the others are also good options. The guaranteed issue law can get a bit complicated at times, and premiums are pretty extreme, so it is important to know your choices and also consider public health plans if you do not earn enough to buy through a health insurance company.
In Massachusetts, health care and personal well being are clearly a priority. Ranked fifth in the country by UnitedHealth Foundation, the state has a low population of uninsured individuals among other characteristics that support being healthy. The number of adults who smoke in Massachusetts is significantly less than other states, and continues to decline over time. Though the number of obese individuals has increased over the past ten years, there is a smaller percentage than many other areas in the country. There is also an ample amount of primary care doctors available throughout the state.
A few areas of improvement, as nobody’s perfect, include the large number of adults who drink excessively. There is also a frequent number of preventable hospitalizations in the state. Diabetes has also become more prevalent among adults in Massachusetts, now affecting 7.4% of the population, whereas ten years ago it was 5.4%. From 2010, the state became less healthy overall, which could be turned around if more residents took initiative to tend their health issues, eat better and exercise regularly. Making lifestyle changes and using health care is essential to improving these issues in the future.
Health Insurance Plans
Harvard Pilgrim Health Care
- HMO plans from HPHC in Massachusetts connect you to a network of providers, with care directed by your primary care physician. These plans offer immediate benefits for a copay, such as doctor’s office visits, emergency room care and allergy injections, and your PCP will give you referrals for certain services. Preventive care is offered for no cost with your primary care doctor or another HMO provider. This network contains many doctors and hospitals throughout the state. Core Coverage HMO plans have various deductibles to choose from, and after you meet the deductible you pay an amount of coinsurance for inpatient and outpatient medical services and diagnostic work.
Fallon Community Health Plan
- HMO plans come in many options, with the ability to have a deductible of $1,000 or $2,000 or no deductible at all. Many of these plans cover your major medical bills at 100%, though there are a few plans (Premium Saver) that only cover 65%. Primary care office visits are available from the start of your plan for a $25 copay, and preventive care is no cost. Due to high monthly premiums, some of these plans can operate with no deductible or coinsurance. Maternity and prescription coverage is included, as well as various inpatient and outpatient hospital services for a copay.
Public Health Options
The state of Massachusetts has a number of government-funded programs to assist low-income individuals who do not have health insurance. If you cannot afford health insurance coverage in the state and meet certain income criteria, you may be eligible for MassHealth, the state’s Medicaid program that provides several types of individuals with medical insurance. For further information on who can receive MassHealth benefits, go to our Medicaid Eligibility by State page. Other programs and services are also available for uninsured residents with specific illnesses or who want to be screened for diseases and conditions. To see a full list of available care, visit the Office of Health & Human Services.
- MassHealth: medical insurance for uninsured, low-income families, children, pregnant women, adults over 65, and individuals with disabilities.
- Health Safety Net: health care services through hospitals and community health clinics for residents without insurance or who do not have adequate coverage.
- Commonwealth Care: health insurance program for adults without insurance and meet other criteria to receive a variety of benefits.
- Mass in Motion: promotes healthy eating and physical activity and other guides to wellness.
Health Insurance Laws
In Massachusetts, various laws influence the operation of the individual health insurance market. As mentioned, guaranteed issue is upheld by private insurers for individual plans as well as group policies. This works with an open enrollment period, which takes place from July 1 to August 15 each year. There is an exception to the guaranteed issue laws, which regards individuals with pre-existing conditions. Massachusetts insurers are not required to accept persons with their definition of a pre-exsiting condition, which is anything for which someone has received medical attention before applying for health insurance.
Health insurance companies can do several things if they decide to insure someone with a pre-existing condition. Firstly, premiums go up as with any other high-risk individual like a smoker, and an exclusion period may be issued for up to six months. This means your plan will cover regular medical services, but not pay for treatment of the condition. Elimination riders are not permitted in Massachusetts, so a six month maximum is the most anyone will experience. Also, if the applicant has had a health plan in good standing before the one they are currently receiving, they can use the old plan as a credit to pay for care during the exclusion period.
Individuals with pre-existing conditions have an alternative for medical coverage, called the Pre-Existing Condition Insurance Plan. This program was organized by the Affordable Care Act and gives reasonably priced, state-funded plans to adults with pre-exsiting conditions. PCIPs are meant to be a temporary solution until January 1, 2014, when all insurance companies will be required to insure adults with such conditions. At that point, insurance companies in Massachusetts will have to provide coverage without the use of exclusion periods.
It is also a right of the individual who has health insurance to continue use of their plan regardless of getting sick during their term. Guaranteed renewability makes sure that not only an insurer cannot cancel benefits based on health, but they have to offer to renew the same plan for another year. This creates protection for the insured individual in Massachusetts to maintain continuous coverage. An insurer only has the right to terminate benefits on the grounds of fraud, violation of agreement, or neglect of payment obligations.