In Massachusetts, you can choose from a wide variety of health insurance plans. Prices will vary depending on the type of coverage and your health status. In this article we will explain everything you need to know about Health Insurance in Massachusetts so that you can choose the one that best suits your needs.
Since 2006, Massachusetts law requires residents to have health insurance coverage. Not having it can carry a state tax penalty, even after the Personal Responsibility Payment of the Affordable Care Act was repealed.
What is health insurance?
The purpose of health insurance is to offer you protection from a financial point of view with respect to possible expenses resulting from treatment for injuries and/or illnesses that may result from medical, hospital or specialist care.
You can obtain health insurance in several ways, it may be that your employer takes out insurance for you for your work, through a state exchange or individual or family.
It is simple to understand, if you think about it, no one is exempt from having an illness or injury at some point, and if you do not have health insurance it could end your savings.
Health insurance can help you cope with the costs of medical care or drug expenses. So that you can better understand the terms that are used when we explain health insurance and handle better information when comparing, we present some basic concepts that you should know.
It refers to the payments that are made to the insurance company so that your policy remains active.
When you contract an insurance policy, you can choose the monthly or total payment for the time of coverage, or some other financing plan that the company makes available to you.
A copayment is a fixed dollar amount that you pay directly to a doctor, hospital, or pharmacy at the time you receive the service. For example, you pay $30 for an office visit and the plan pays the rest.
A plan may have different copays for different types of services. For example, the copayment for a primary care visit can be $30 while the copayment for an emergency room visit can be $150.
The coinsurance is a percentage of the allowable charge you pay for a covered service. For example, you pay 20% of the cost for a covered office visit, and the plan pays the rest.
A deductible is the amount you pay before the plan begins to pay for most covered services. Typically, you must pay the deductible first, and then the other cost sharing, such as copays and coinsurance, begins.
For example, you must pay a $2,500 deductible for your health care services each year before the plan pays any amount on your bills.
Some health plans have a limit on the visits allowed for a specific covered service. For example: the plan may allow only 10 visits to a chiropractor.
Exclusions are specific services for which there is no benefit. For example, the plan may exclude (not pay for) cosmetic surgery and you will pay the full cost of the service.
An out-of-pocket maximum is a limit on cost sharing for one year. Once your cost-sharing amounts reach the out-of-pocket maximum, the plan pays 100% of covered services for the remainder of that year.
Types of health insurance plans in Massachusetts
There are different types of health plans in Massachusetts, you should be sure to find the one that suits your needs and your income.
Among the health insurance plans in Massachusetts you will find:
Health Maintenance Organizations (HMO)
The HMO plans cover hospital, medical and preventive care. You are only covered if you receive care from the HMO’s provider network (except in an emergency). With most HMO plans, you must pay a copayment for each covered service. For example, you will pay $30 for an office visit and the HMO pays the rest of the cost.
Preferred Provider Plans (PPO)
Preferred provider plans generally cover hospital, medical, and preventive care. These plans have a preferred provider network that you can use, but they also cover services for out-of-network providers. However, PPP will cover a higher percentage if you use a network provider. Example: After copayments and deductibles, the plan pays 100% of a service for a network provider, but 80% for an out-of-network (OON) provider. Note that if you decide to go OON when you are in a PPP, your provider may bill you directly for the full cost of the procedure.
Indemnity plans or Point of Service (POS) plans
These plans generally cover medical and hospital expenses in the event of an accident or illness. Some of them may also cover preventive care and office visits. They usually cover a percentage of the costs. Example: the plan pays 80% of your hospital stay and you must pay the remaining 20%. With these plans, you have coverage for any licensed health provider.
MassHealth Program (Medicaid)
The Massachusetts Medicaid (MassHealth) program offers different types of coverage depending on your age and your particular conditions. MassHealth will decide if you are eligible to enroll in the program and will offer you the most comprehensive coverage for which you are eligible. You can apply online at the Massachusetts Health Connector website .
Medicare is a federal health care program for the elderly and disabled. In Massachusetts, this program works in a similar way to the rest of the country. You will be eligible for Medicare benefits if you are 65 or older, if you qualify for disability, or if you have certain health conditions.
There are several coverage options within the program, including supplemental coverage plans and Parts A, B, C, and D. As a Massachusetts resident, you may also qualify for state-specific Medicare savings programs.
Massachusetts Health Insurance Companies
Massachusetts residents have many options when it comes to health insurance companies. Here are some companies that offer individual and family plans in this state.
BMC HealthNet Plan
BMC HealthNet Plan has several types of plans. Qualified health plans cover prescriptions, hospital stays, mental health services, drug abuse, and more. Plan types are organized into metal tiers: bronze, silver, gold, and platinum. The company also offers discounts on glasses, money back for participating in some health clubs, and nutritional counseling.
BMC HealthNet Plan is a not-for-profit health plan. Established in 1997 by Boston Medical Center, the company serves 330,000 members throughout Massachusetts.
Fallon Community Health Plan
Fallon Community Health Plan offers a large number of group and non-group health plans. These include: HMO, POS, PPO, Medicaid, and Medicare Advantage plans. Most Fallon Health plans don’t require copays for preventive services, eye exams, hospital care, chiropractic care, and more. In addition, the plans cover the costs of drugs prescribed by network doctors. Members enjoy benefits like a new parenting program, a smoking cessation program, exercise discounts, and more.
Fallon Health was founded in 1977 and is one of the top-rated health plans in the country. The company’s mission is to “make our communities healthy.”
Health New England
Health New England offers health care plans through the MA Health Connector. Members can access care management programs through New England Health. These programs focus on behavioral health, disease management, complex care management, and care coordination. Members can also speak with a doctor online or by phone 24 hours a day, 7 days a week. You can log in to their member portal if you want to calculate the price of medical services and plan the costs.
Health New England was founded in 1985. The company has a network of 23 hospitals and 11,000 providers. Health New England serves the following MA counties: Berkshire, Franklin, Hampden, Middlesex, Norfolk, and Worcester.
Allways Health Partners
Allways is a local health insurance provider offering a variety of HMOs and PPOs. Specific benefits vary between plans, but members enjoy pharmacy benefits and discounts through CVS. The company offers family support for moms-to-be, help to quit smoking, health coaches, and more.
Tufts Health Plan
Tufts Health Plan offers two different plans for individuals and families: Direct and Premier. These plans are sold on the MA Health Connector. Direct offers low-cost plans and, if you qualify, federal premium tax credits. Premier members have access to the standard Tufts Health Plan network. Plans affect the network of doctors you have access to, so some doctors may be available in one network but not the other. Plan benefits include gym membership reimbursements, a stress management program, vision correction and glasses, and more.
Tufts Health Plan serves 1.1 million members and has a network of more than 100 hospitals and 51,000 providers.
Harvard Pilgrim Health Plan
Harvard Pilgrim Health has several plans that are offered in metal tiers: bronze, silver, gold, and platinum. Types of plans include HMO, PPO, and Connector. Individual and family plans also include various benefits, such as personal health counseling, a $0 copay for annual physicals, annual flu shots, gym discounts, and more. All plans cover emergency services, hospitalization, prescription prescriptions, and more.
Harvard Pilgrim Health Plan has been serving Massachusetts residents for 50 years. The company has a network of more than 70,000 doctors and 182 hospitals.
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of MA offers six types of plans for individuals and families. These plans are HMO, PPO, Access Blue, Blue Options HMO, Blue Options PPO, and Blue Select HMO. There are also several options outside the network. Deductibles for BCBSMA plans typically range from $ 500 to $2,000. Member benefits include a 24/7 Nurse Advice Line and an online tool that allows live video chats with physicians. BCBSMA also offers programs that focus on overcoming insomnia and pregnancy and postpartum care.
BCBSMA was founded in 1937 and employs 3,700 people. The company’s vision is “to make quality healthcare affordable.”
Massachusetts health insurance prices
Massachusetts residents spend an average of $10,559 per year on health care. This figure exceeds the national average. But what factors determine the price of health insurance? Here are some of the aspects that insurance companies take into account when setting the price of your policy:
Type of health insurance plan
Marketplace plans typically divide coverage into metal tiers: bronze, silver, gold, and platinum. The more coverage you want, the more you pay in monthly premiums.
Here are the average monthly premiums for a 40-year-old Bay State resident in 2021:
- Bronze: $259
- Silver: $324
- Gold: $386
The cheapest insurance plan is bronze. However, there is a 50% price jump from a bronze plan to a gold plan. This is because gold plans cover 80% of health care costs, while bronze plans cover 60%.
You may qualify for catastrophe plans available to people under the age of 30 or with certain exemptions. These plans have low monthly premiums but a high annual deductible of $8,150. Investing in a bronze or silver plan can save you a lot of money if you need to use your health insurance.
Body mass index
A high body mass index can lead to several serious health problems. That is why insurers take this factor into account to determine your level of risk. A high BMI often leads to higher insurance rates.
In 2018, Massachusetts had an obesity rate of 25.7%, the fourth-lowest rate in the country.
It’s no secret that smoking carries substantial risks. About 13.7% of Massachusetts residents are smokers, the fifth-lowest rate in the country.
Health insurance tends to be more expensive for older people than for younger people.
Laws, regulations, and insurance providers in your state play an important role in insurance costs.
The rates also depend on the people nearby. Insurers often use community ratings to determine their costs. That means their monthly premiums are also based in part on the claims everyone files. If your neighbor files a large number of claims, for example, their costs could reflect that.
That means living in a health-conscious state could keep your premiums lower. In this case, there is good news for residents of Massachusetts, this is the healthiest state in the country.
Massachusetts Health Insurance Laws
The Affordable Care Act requires that insurance companies cannot use certain factors to price their policy.
- Pre-existing conditions: Providers used to charge people with pre-existing conditions significantly more for health care coverage than those without. Currently, insurance companies can no longer charge you more if you have a pre-existing condition.
- Gender: According to a Health Services Research study, women tend to pay more for health care. But the ACA now prohibits providers from charging different prices to women and men.
- Insurance and medical history: Before the ACA, people with previous medical conditions or lapses in insurance coverage paid higher rates. This type of policy is now illegal.
Massachusetts law requires insurance companies to provide at least some coverage for the following services:
- Intensive care
- Emergency services
- Maternity health care
- Speech, hearing, and language disorders
- Clinic tests
- Prosthetic devices
- Speech therapy
- Mental health care
What is not covered by health insurance?
In the same way, as in the case of what medical insurance covers; health and medical expenses not foreseen in the policies may vary. But generally, what a Massachusetts health insurance plan doesn’t cover includes:
- Elective or cosmetic procedures.
- Long-term nursing home care.
- Infertility treatments.
- Alternative therapies.
- Dental, vision and hearing treatments.
Regarding the dental, visual and hearing care service; the insurance companies are typically included in basic services for children and adults as an extra.
The main mission of the Division of Insurance (DOI) is to monitor the creditworthiness of insurers to promote a healthy and responsive market for consumers who purchase insurance products.