Health Insurance Marketplace in Massachusetts

If you live in Massachusetts, the Health Connector is the Health Insurance Marketplace to serve you. Instead of, you’ll use the Health Connector website to apply for coverage, compare plans, and enroll.  Visit the Health Connector now to learn more.

Choosing the Right Health Insurance Plan

There are a number of different tiers of plans available on the Massachusetts Health Insurance Exchange. Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the Massachusetts insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Massachusetts health insurers don’t have to offer every tier of plan, but within the Massachusetts health insurance exchange, all health insurance companies must offer at least one silver plan and one gold plan to consumers.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Massachusetts will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in Massachusetts 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Information for:

Individuals and Families

Small businesses

If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.

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Consumer Operated and Oriented Plan Program

Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets.  CO-OP in Massachusetts:

Minuteman Health

Accountable Care Organizations in Massachusetts

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

Models Run at State Level

Health care facilities where Innovation Models are being tested

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Massachusetts

On April 12, 2006, former Governor Mitt Romney (R) signed into law comprehensive health reform legislation designed to provide near-universal health coverage for state residents.1 The Massachusetts health reform law became the model for national health reform.

An important component of the law was the creation of the Massachusetts Health Connector, a health insurance exchange that manages several coverage programs. Commonwealth Care provides subsidized coverage for individuals with incomes below 300% of the federal poverty level ($33,510 for an individual and $69,150 for a family of four in 2012) and Commonwealth Choice enables those who are not eligible for Commonwealth Care to shop for and purchase insurance offered by private health plans. In 2010, the Massachusetts Connector launched the Business Express program for businesses with 50 or fewer employees. As of December 2012, the Connector enrolled over 225,000 individuals in coverage—over 190,000 in Commonwealth Care and more than 40,000 in Commonwealth Choice, including approximately 4,750 enrollees in Business Express.2 Enrollment is expected to continue to increase in fiscal year 2013, in part due to reintegration of legal immigrants who became eligible for enrollment in the Connector after a recent Massachusetts Supreme Court decision.

In 2012, Governor Deval Patrick (D) enacted two laws affecting the Connector.3,4 The first authorized the Connector to be certified as a state-based exchange as defined in the Affordable Care Act (ACA) and gave the Connector authority to perform key tasks, such as establishing a Navigator program and administering appeals related to the federal exchange. The second law included a number of provisions related to the ACA, including: designating the Connector as the entity to conduct risk adjustment; authorizing the Connector to sell stand-alone dental, vision, catastrophic, and child-only plans; and designating the Health and Human Services Department (known as MassHealth) to administer the Basic Health Plan option.

Structure: The Massachusetts Connector was established as a quasi-governmental organization, specifically a “public entity not subject to the supervision and control of any other executive office.”

Governance: The Connector is governed by an 11-member Board, including four ex officio members (or designees): Secretary for Administration and Finance, Director of Medicaid, Commissioner of Insurance, and Executive Director of the Group Insurance Commission. The Governor appoints an actuary, a health economist, a representative of small business, and an underwriter. The Attorney General appoints an employee health benefits specialist, a representative of health consumers, and a representative of organized labor. Appointees cannot be employed by an insurance carrier licensed in Massachusetts.

Current appointed Board members are:

  • Ian Duncan, Solucia Inc.
  • George Gosner Jr, Spring Insurance Group
  • Jonathon Gruber, Massachusetts Institute of Technology
  • Andrés López, AJL Consultants
  • Louis Malzone, Massachusetts Coalition of Taft-Hardly Funds
  • Nancy Turnbull, Harvard School of Public Health
  • Celia Wcislo, 1199 SEIU United Healthcare Workers East

Contracting with Plans: The Connector acts as an active purchaser and requires health insurance carriers offering plans through the Connector to receive the “Seal of Approval” by meeting requirements such as participation in all Commonwealth Choice offerings (meaning individual and small group) and offering all standardized benefit packages for all plan benefit levels (gold, silver, bronze, and young adult plans). Carriers may also offer non-standardized products to consumers, and the Connector is considering displaying these plans within the corresponding metal tiers (as suggested by an actuarial review).5 For 2013 plan year, the Connector received proposals from all eight existing Commonwealth Choice carriers and one new entrant, and granted the Seal of Approval to all standardized and non-standardized plans.

The Seal of Approval process provides the framework for the Connector’s certification, recertification, decertification, and ongoing performance monitoring processes. It is substantially in compliance with the Affordable Care Act’s (ACA) qualified health plan certification standards and only a few refinements are necessary.

However, in order to comply with the metal tier requirement in the ACA, the Health Connector is considering maintaining a base of standardized and non-standardized plans for both the individual and small group exchanges, and to include additional non-standardized plans for the small group market only.6 The additional non-standardized plans would not be available in the individual exchange but must be made available through other channels (such as directly from the carrier) to be consistent with state and federal regulations. Carriers would be required to offer at least one plan for each standardized benefit package on their broadest commercial network. The Connector plans to release the 2014 Seal of Approval Request for Responses (RFR) in January 2013.

Dental and Vision Benefits: The Health Connector plans to include stand-alone dental plans beginning in 2014 and using a dental Seal of Approval program in parallel with the medical benefit. The RFR release date for dental plans is targeted for January 2013.

Risk Adjustment, Reinsurance, and Risk Corridors: Massachusetts will administer the Connector’s risk adjustment program. A multi-agency workgroup, co-chaired by the Connector and Division of Insurance, is developing the methodology and plans to leverage the state’s existing All-Payer Claims Database.7 The Division of Insurance will also oversee administration of the transitional reinsurance program.

Consumer Assistance and Outreach: The state has also begun planning an outreach and education initiative that builds on previous public education campaigns and an established foundation of stakeholder engagement.8 The Connector will continue working with inter-agency partners to conduct a new assessment of the environment, identify remaining needs, and define an effective strategy to reach individual consumers and small businesses. These initiatives will be a key component of the multi-year plan to increase public awareness and involvement and to establish a Navigator program to facilitate enrollment. In December 2012, Massachusetts concluded the competitive bidding process to identify a vendor to assist with communications over the next year. The vendor will develop a style guide for the Health Connector and MassHealth and will design the print and electronic communications for individuals, employers, Navigators, and brokers.9

Small Business Health Options Program (SHOP) Exchange: The Division of Insurance has identified a subcontractor to evaluate the impact on the insurance market of broadening the definition of small employer to those with 100 or fewer employees before 2016.10

The Health Connector is creating “Sub-connectors,” an alternative distribution channel for small employers (and the brokers who serve them) to purchase coverage through the Health Connector while retaining aspects of their current shopping experience. The goal is to allow more small businesses to access QHPs through the Connector.11 The Health Connector has issued a Request for Information (RFI) to collect feedback on licensing requirements for Sub-connectors.

The Health Connector is contemplating an employee choice model in which employees choose from all QHPs within an employer-selected level of coverage. The Connector hopes to leverage knowledge acquired from the Contributory Plan pilot, which was frozen shortly before the Business Express was introduced in 2010. The Contributory Plan allowed employers to fix their contribution to premium costs, while still providing meaningful plan choice to employees. Previous experience with the Contributory Plan indicated that the concept appealed to employers but there were opportunities for improvement to make the methodology consistent across carriers and ensure the shopping experience was simple and intuitive.

Information Technology (IT): The current IT structure in Massachusetts includes two eligibility systems: MA21 (for Medicaid and the Children’s Health Insurance Program or CHIP) and Beacon (for the Supplemental Nutrition Assistance Program or SNAP and the Temporary Assistance to Need Families program or TANF). By 2015, Massachusetts plans to have integrated the two systems into a single eligibility hub which assesses eligibility for Medicaid, CHIP, TANF, SNAP, the Health Safety Net (or HSN, the state’s free care program), and subsidized private coverage in the Connector.12

The Massachusetts Executive Office for Health and Human Services (EOHHS), the Connector, and the University of Massachusetts Medical School are collaborating to develop the Health Insurance Exchange and Integrated Eligibility System (HIX/IES). To support this initiative, the state received both federal exchange grants and the EOHHS applied for and received CMS approval of an Advanced Planning Document for the enhanced federal match to upgrade the state’s Medicaid eligibility systems.13 In December 2011, the state released a Request for Resources (RFR) to identify a vendor to act as a Systems Integrator that would design, develop and implement the HIX/IES for Massachusetts’s multiple health care programs.14

In November 2012, the Health Connector issued a Request for Proposals (RFP) for subcontractor assistance with creation of a single, integrated system that replaces the separate customer service and business operations programs currently used for Commonwealth Care and Commonwealth Choice.15 The subcontractor would need to create a program that interfaces with the technology systems being built through the HIX/IES project, implement technology systems to manage premium billings and contracts, establish and maintain a call center, create new tools for members like web-chat and an email message center. The three-year contract would start in March 2013 and could be extended for three additional one year extensions.

Massachusetts is a member of the New England States Collaborative Insurance Exchange Systems (NESCIES), a learning collaborative led by a multi-state steering committee. Other participating states are Connecticut, Maine, New Hampshire, Rhode Island, and Vermont. Through the Collaborative, participating states can share innovative technology components and best practices for implementing insurance exchanges and integrated eligibility systems.16 The NESCIES has created a Procurement Management Team to purchase components necessary to develop an IT system in Massachusetts and other states. In May 2012, Massachusetts issued an RFR for independent verification services to assist this team.17

Massachusetts is also participating in the Enroll UX 2014 project, which is a public-private partnership creating design standards for exchanges that all states can use.

Basic Health Program (BHP): In June 2012, MassHealth was authorized to create a BHP.18 The BHP is an optional bridge program available through the ACA which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139% and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. In addition, the Connector was authorized to make wrap-around premium and cost-sharing subsidies available individuals covered by qualified health plans through the Health Connector if their incomes are between 200% and 300% of FPL. The wrap-around subsidy is meant to hold the new premiums for individuals with incomes up to 300% FPL in line with the current premiums for Commonwealth Care.

However, given the delay in federal guidance detailing the administration of a BHP, Massachusetts is now considering an alternative proposal that would provide state-based wrap-around subsidies for individuals with incomes between 139% and 300% FPL who are enrolled in specified QHPs.19Only carriers that offer the lowest-priced QHPs will be qualified to offer the wrap plans. The level of the wrap-around subsidies may depend on the availability of federal funding through an 1115 demonstration waiver.

Essential Health Benefits (EHB):  The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Along with collecting stakeholder feedback, the Division of Insurance compared the ten possible EHB benchmark plans and concluded that the three largest small group plans offered in Massachusetts offer similar benefits and have virtually the same relative value.20 Massachusetts selected Blue Cross Blue Shield’s HMO Blue, the largest small group plan, as the EHB benchmark.21 The DOI also recommended that the benchmark plan be supplemented with the state’s CHIP pediatric dental benefit plan.

Exchange Funding

The DHMH has received three federal grants: an Exchange Planning grant of $1 million; an Early Innovator grant of $6.2 million to develop an exchange IT infrastructure that could be replicated by other states; a Level One Establishment grant of $27 million to conduct data and policy analysis that will inform the technical and operational infrastructure of Maryland Health Connection and enable rapid implementation of the IT platform; and a Level Two Establishment Grant of $123 million to support continued policy development and consumer outreach, assistance, and education.25,26

In addition, Maryland, along with nine other states, is receiving technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.27

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Massachusetts is participating in Medicaid expansion.

Next Steps

On December 7, 2012, Massachusetts received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.25 Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.

Multiple state agencies have begun to coordinate and plan for a third ACA-reconciliation bill, currently slated for the 2013 legislative sessions.26 This bill will likely include a compilation of technical changes to previous state health reform legislation and additional substantive changes that reflect policy-decision making by various advisory committees and workgroups.

Additional information about the Massachusetts Connector can be found at:

1. Chapter 58. An Act Providing Access to Affordable, Quality, Accountable Health Care. April 12, 2006. and Part I, Chapter 176Q. Administration of the Government, Commonwealth Health Insurance Connector.
2. Massachusetts Connector Quarterly Program Summary Report, November 2012. December 3, 2012.
3. Chapter 96. An Act Making Appropriations for the Fiscal Year 2012 to Provide for Supplementing Certain Existing Appropriations and For Certain Other Activities and Projects.
4. Chapter 118. An Act Making Appropriations for the Fiscal Year 2012 to Provide for Supplementing Certain Existing Appropriations and For Certain other Activities and Projects.
5. Stephany S and Yang J. “Commonwealth Choice 2013 Seal of Approval.” Presented to the Health Connector Board of Directors. September 13, 2012. (Accessed here)
6. Yang J, Kenney K, Keen A. “2014 Seal of Approval Introduction (II): Product Strategy and Employee Choice.” November 8, 2012. (Accessed here)
7. Apicella D and Berardi C. “National Health Care Reform Update” Presented to the Health Connector Board of Directors, September 13, 2012. (Accessed here)
8. Massachusetts Health Connector Board Retreat Presentation. “National Health Care Reform: Key Context, Planning and Implementation Issues for the Health Connector.” December 3, 2011. (Accessed here )
9. Nichols S. “Communications Consultant Procurement.” December 13, 2012. (Accessed here)
10. Massachusetts Excecutive Office of Health and Human Services. “Health Insurance Reform Working Group: ACA Changes to Small Employer Definition and Rating Factor Rules.” March 23, 2012.
11. Mansur R. “Licensing Procedures Request for Information.” November 16, 2012. (Accessed here)
12. Presentation by Jay Himmelstein and Angela Sherwin from the New England States Collaborative for Insurance Exchange Systems. “Health Insurance Exchanges and ‘Resusability’ of IT Components: Early Lessons from The England States Collaborative for Insurance Exchange Systems (NESCIES).” December 7, 2011. (Accessed here on August 15, 2012.)
13. Massachusetts Health Connector Board Retreat Presentation. December 3, 2011.
14. RFR for Massachusetts Health Insurance Exchange and Integrated Eligibility System MA HIX/IES: Systems Integrator Procurement. Open Date 12/21/2012. (Accessed here)
15. Mansur R and Bullock J. “Customer Service Technology and Business Operations Services.” November 16, 2012. (Accessed here)
16. New England States Collaborative for Insurance Exchange Systems.
17. RFR for Massachusetts Health Insurance Exchange and Integrated Eligibility System Independent Verification and Validation Services (CW12-JD-0038-0001 RFR).
18. Chapter 118. An Act Making Appropriations for the Fiscal Year 2012 to Provide for Supplementing Certain Existing Appropriations and For Certain other Activities and Projects.
19. Yang J and Hague A. “2014 Seal of Approval Introduction (III): Subsidized Health Insurance and the QHP Wrap.” December 13, 2012. (Accessed here)
20. Executive Office of Health and Human Services. “Analysis of Three Largest Small Group Plans for EHB Benchmark.” September 19, 2012. (Accessed here)
21. Essential Health Benefits, Benchmark Plan for Massachusetts. Accessed January 8, 2013.
22. Massachusetts Health Insurance Connector Authority application for Level One Establishment grant. Project Abstract. December 27, 2011.
23. Massachusetts application for the Cooperative Agreement to Support Innovative Exchange Information Technology Systems. IE-HBE-11-001. The New England States Collaborative Insurance Exchange Systems (NESCIES)
24. Massachusetts Affordable Insurance Exchange Grants Awards List.
25. Letter from Secretary Sebelius to Governor Patrick. December 7, 2012.
26. Presentation by Ashley Hague, at the Health Connector Board of Directors Meeting. “Health Connector ACA Legislative Update.” July 12, 2012. (Accessed here)

Provided by the Henry J. Kaiser Family Foundation


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