Massachusetts Health Insurance

Published: August 25th, 2015

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Massachusetts is considered one of the healthiest states in the country, with the lowest percentage of residents who are without health insurance coverage.1 Out of its population of 6.6 million people, just 2.8% — about 180,000 — are uninsured, significantly lower than the national average.2

If you’re one of the thousands of people within the state who don’t have health insurance, learn about your options to get affordable coverage. 

Health insurance options in Massachusetts

Insurance costs in Massachusetts tend to be fairly low. In terms of the average premium for the lowest-cost silver plan, Massachusetts is one of the cheapest states in the country. Only Rhode Island and Minnesota have lower average premiums.3

However, Massachusetts stands out from other states in two key ways: 

  • Individual mandate: Since 2007, adults within the Commonwealth are required to have coverage that meets state standards. If you don’t comply with the individual mandate, you could face a penalty as large as $1,524 per year.4
  • Short-term insurance plans: Short-term insurance plans, which are temporary insurance policies people use as affordable alternatives to private health insurance, aren’t an option in Massachusetts. Under current state law, underwritten short-term plans are not permitted.5

The introduction of the Affordable Care Act (ACA) had a significant impact on the state. In just three years after the launch of ACA, the number of uninsured individuals in Massachusetts declined by over 30%.6 Today, the state’s percentage of uninsured people is below the national average.

In 2013, then-governor Deval Patrick signed legislation to expand Medicaid under the ACA, covering adults earning up to 138% of the federal poverty line.7 Under the new regulations, an additional 393,000 people were able to get health insurance coverage through Medicaid.8

Due to these changes, you have more coverage options in Massachusetts. If you need health insurance, your choices are dependent on your age, income, and employment status. 

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Individual health policies

You can sign up for coverage through the Massachusetts Health Connector, the state’s version of the Affordable Care Act’s Health Insurance Marketplace. As of 2020, there are 10 different insurance companies that offer medical and dental insurance on the Health Connector portal.9

To qualify for coverage, you must apply for a plan during the Open Enrollment Period (OEP). Massachusetts has a longer OEP than other states; it runs from November 1 until January 23.10

If you miss the OEP, you may be able to sign up for a plan if you have a qualifying life event that makes you eligible for a Special Enrollment Period (SEP). A SEP is a 60-day period after a qualifying event, including: 

  • Getting married
  • Having a child
  • Losing your job
  • Moving to the state11

You can apply for a health plan at MAHealthConnector.org

Individual mandate

In Massachusetts, residents over the age of 18 who can afford coverage must have health insurance or pay a penalty through their tax returns.

Your insurance policy must meet minimum creditable coverage regulations. To avoid penalties, your policy must meet those following criteria: 

  • Coverage for comprehensive services, including doctor visits, hospital admissions, and prescription drugs
  • A cap on annual deductibles of $2,000 for individuals and $4,000 for families
  • Out-of-pocket maximum of $8,150 for individuals and $16,300 for families for 2020
  • If there is a separate prescription drug deductible, it cannot exceed $250 for an individual or $500 for a family

If you don’t have adequate insurance, there is a penalty. The amount of the penalty is based on your income, age, and family size.

There is no penalty if your income is at or below 150% of the federal poverty level.12

Premiums

Affordable Care Act and MA Health Connector plans are divided up by categories, referred to as metal tiers. There are bronze, silver, gold, and platinum tiers. Bronze plans have the cheapest premiums, but the insurance company will pay the lowest percentage of your medical costs (60%). On the other end is platinum plans. While platinum plans have the highest monthly premiums, the insurance plan will cover the highest percentage of your covered care (90%).13

In terms of premium, Massachusetts has one of the lowest average benchmark premiums in the country with a cost of just $343 per month. Only Rhode Island and Minnesota are lower.14

How much your premium will be is dependent on what tier of coverage you choose. Here is what the average premium is by metal tier for 2018 through 2020:15 

Average Lowest-Cost Bronze PremiumAverage Lowest-Cost Silver PremiumAverage Lowest-Cost Gold Premium
201820192020201820192020201820192020
$252$257$259$307$323$324$378$363$386

Subsidies

You may expect private health insurance to be prohibitively expensive. However, you may be surprised by how affordable it can be. Depending on your income, you may qualify for the advanced premium tax credit or cost-sharing reductions.

In Massachusetts, the average insurance premium is $392. But the average premium after applying for the advanced premium tax credit — a subsidy that can lower your costs — the average premium is just $204.16

With cost-sharing reductions, you could qualify for a discount that lowers the cost of your deductibles, copayments, and coinsurance. If you qualify for a cost-sharing reduction, you must enroll in a silver tier plan to get the discount.17 

Medicaid and CHIP

In Massachusetts, there are over 692,000 people living in poverty.18 If you’re struggling to make ends meet, you may think about forgoing health insurance to save money. However, that can be an expensive mistake. A single medical emergency can cost you thousands, leading you into debt.

Luckily, Massachusetts does have programs in place to help low-income people get essential healthcare.

In Massachusetts, Medicaid and the Children’s Health Insurance Program (CHIP) are combined to form MassHealth. Eligible members of MassHealth can get coverage for doctor visits, prescription medications, hospital stays, and more.19

To be eligible, you must be a resident of the state, a U.S. national citizen or qualified noncitizen, and have a financial situation that can be categorized as low-income or very low-income.

Your income must be less than or equal to the following amounts:

Household SizeMaximum Income Per Year13
1$16,612
2$22,491
3$28,369
4$34,248
5$40,127
6$46,005
7$51,884
8$57,762

For households with more than eight people, add $5,878 per additional person

As of December 2019, over 1.5 million people are enrolled in Medicaid and CHIP.20

You can apply online at MAHealthConnector.org

MEDICARE

Medicare is typically for people over the age of 65, but there are some exceptions. You can qualify for Medicare if you have been entitled to Social Security benefits or Railroad Retirement Board disability benefits for the past 24 months, have Lou Gehrig’s Disease, or are a kidney dialysis or kidney transplant patient. 

  • Original Medicare: Medicare covers services like doctors’ services, outpatient care, and prescription medications.21 
  • Medicare Advantage: There is also Medicare Advantage, an all-in-one alternative to Original Medicare. These are bundled plans that have different costs than Original Medicare.22
  • Medicare Part D: Medicare Part D provides prescription drug coverage.

In Massachusetts, about 1 million people are enrolled in Original Medicare, and approximately 280,000 are enrolled in Medicare Advantage Plans.23 About 700,000 people in Massachusetts have standalone Medicare prescription drug coverage.24

If you are 65 or older, you may be eligible for Medicare. If you or your spouse worked and paid Medicare taxes for at least 10 years, you can even qualify for premium-free Medicare Part A, meaning you can get health insurance without having to pay monthly premiums.

However, you may be able to buy into the system even if you didn’t pay Medicare taxes while you worked.

Depending on your needs, you may decide to add Medicare Part B coverage to your policy, as well. The monthly premium for Medicare Part B is deducted from your Social Security, Railroad Retirement or Civil Service Retirement checks. To find out if you’re eligible for Medicare, use the Medicare Eligibility Calculator.25

Another option is Medicare Supplement Insurance or Medigap. While Original Medicare pays for most of your covered health care services and supplies, it doesn’t cover everything. A Medigap policy can help pay for remaining costs, including your deductibles, copayments, and coinsurance.26 

If you’re unemployed

If you lost your job or left for a new opportunity and are waiting for your coverage to kick in, there are a few different health insurance options available to you. 

COBRA

Under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), you can extend your existing coverage for up to 18 months. However, you are responsible for paying for your entire premium, which can be very expensive.27

Mini-COBRA

Massachusetts passed a law in 1996 that required small group health carriers to provide continuation of coverage benefits similar to those required by federal COBRA rules. If you worked for a small employer — a business with two to 19 employees — and lost your job or left for a new one, you can extend your coverage for up to 18 months with mini-COBRA.28

Short-term health insurance

Many people opt for short-term health insurance plans instead of private insurance. Short-term plans don’t have to conform to ACA standards and tend to be much cheaper than private insurance.

However, Massachusetts implemented regulations that made short-term plans follow nearly all of the same rules that ACA plans have. As a result, short-term insurance carriers have opted to not offer any plans in the state, so a limited duration isn’t an option for Massachusetts residents.29 

Applying for health insurance in Massachusetts

Depending on your family size, income, and age, there are several health insurance options for Massachusetts residents. By researching the available plans, you can find coverage that works for your budget. 

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Article Sources
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