Since the passage of the 2010 Patient Protection and Affordable Care Act, all states, including Massachusetts, have been working to bring their insurance regulations in line with the new federal requirements. Significant changes regarding children and insurance have already been made. Children can no longer be excluded for pre-existing conditions and may stay on their parents’ insurance policies until the age of 26 even if they are no longer in school or if they have married.
Almost all the states have established high-risk pools for people with pre-existing conditions that will be replaced by the required federal health care exchanges on January 1, 2014.
General Insurance Regulations
There are no lifetime caps on coverage in Massachusetts and yearly limits are currently set at $1.25 million. All adults are required to purchase a Massachusetts health insurance policy if they can afford it. If not, there are several programs available for low-income adults that provide free or subsidized health insurance.
All insurance policies in the state must provide free coverage for a variety of preventative tests including mammograms, vaccines, smoking cessation counseling, and blood pressure screenings. Once a health policy is in place, it cannot be canceled so as the policy premiums are paid. Insurance companies also cannot deny coverage based on age or health. They can cancel coverage for fraud.
Health Care Exchanges
Building on existing programs, Massachusetts immediately established the required federal health care exchange on the active purchaser model.
Pre-Existing Condition Insurance
The Pre-Existing Condition Insurance Plan in Massachusetts is administered by the U.S. Department of Health and Human Services and includes benefits for primary, secondary, and hospital care as well as prescription medications. According to age and option chosen, premiums run from $181 to $778 a month. Deductibles are $1000 to $3000 and in some cases there is a separate drug deductible. Combined out-of-pocket expenses in and out of the network cannot exceed $7000 annually.
All Medicaid eligibility is determined by income as a percentage of the Federal Poverty Level, the same formula used for disbursing benefits from the Children’s CHIP-funded Medicaid Expansions. Infants under the age of 1 year qualify for Medicaid at 185 and 200% FPL respectively; age 1-5 at 133 and 150; and ages 6-19 at 114 and 150.
Pregnant women may receive Medicaid at 200% FPL, parents at 133, childless adults with long-term unemployment at 100, and disabled Social Security recipients at 74.
With the health care reforms taking place, Massachusetts’ program for low income children, MassHealth was expanded to increase the family income eligibility requirements up to 300% of the federal poverty law. It also helped to restore several benefits that were previously denied including eyeglasses and dental care. For low-income individuals who are below 300% of the poverty level, there is the Commonwealth Care Insurance Program. If the income level is below 150% of the federal poverty level, there are no insurance premiums.
Approximately 16 percent of residents in Massachusetts receive Medicare benefits, with more than 1 million accessing prescription drug coverage. The average amount spent annually per enrollee is $8,100.
The Serving Health Information Needs of Elders (SHINE) program provides counseling and education services and helps Medicare enrollees find the best health insurance plan to fit their needs.