Massachusetts Health Insurance Policy Requirements

Massachusetts pioneered comprehensive health reform in 2006, creating the model that would later become the Affordable Care Act. The Commonwealth has robust health insurance regulations under MGL Chapter 176.

Regulatory Structure

Massachusetts health coverage is regulated by the Division of Insurance:

HMO Regulation in Massachusetts

Massachusetts regulates Health Maintenance Organizations (HMOs):

• HMOs must be licensed by DOI
• Must meet net worth requirements
• Required to have quality assurance programs
• Must have grievance and appeals processes
• Must maintain adequate provider networks

Massachusetts Health Connector

Massachusetts Health Connector is the state-based health insurance marketplace:

• Massachusetts operates its own state-based exchange (not Healthcare.gov)
• First state exchange in the nation (2006)
• Offers qualified health plans (QHPs)
• Open enrollment and special enrollment periods
• Premium subsidies available based on income
• Website: mahealthconnector.org

Exam Tip: Massachusetts was the first state to implement comprehensive health reform in 2006 and operates its own Health Connector marketplace.

Individual Mandate

Massachusetts has an individual mandate for health insurance:

• Residents are required to have health coverage
• Penalty for non-compliance on state tax return
• Exemptions available for financial hardship
• More stringent than federal requirement

Required Coverage

Massachusetts mandates coverage for numerous benefits:

Essential Health Benefits

All individual and small group ACA-compliant plans must cover:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorders
6. Prescription drugs
7. Rehabilitative services
8. Laboratory services
9. Preventive and wellness services
10. Pediatric services (including dental and vision)

Mental Health Parity

Massachusetts requires mental health parity in health insurance:

• Mental health benefits must be equal to medical benefits
• Same copays, deductibles, and limits apply
• Covers mental illness and substance use disorders
• Applies to group and individual plans

Pre-Existing Condition Protections

Massachusetts prohibits pre-existing condition exclusions:

Guaranteed Issue and Renewal

Massachusetts requires for health plans:

Guaranteed Issue

• Insurers must accept all applicants
• Cannot deny coverage based on health status
• Applies to individual and small group markets

Guaranteed Renewal

• Insurers cannot cancel coverage except for:
  • Non-payment of premium
  • Fraud or misrepresentation
  • Plan discontinuation (with notice)