Health Insurance in Massachusetts

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Health insurance is crucial for the safety your financial future and your family’s overall health. Protecting your family against the occurrence of illness or injury is difficult; however a suitable health policy can relieve your financial burden caused by these events. When it comes to purchasing health coverage, your top priority should be a thorough assessment of all potential risks and its effect on your finances. In the U.S., approximately 47 million people are uninsured, majority of whom are working families. These families, especially children, end up bearing the brunt of the lack of proper health insurance. For those families who are not covered by their employers’ group plan, there are low-cost state sponsored health insurance programs that provide insurance to these individuals.

Ranked 6th by the United Health Foundation, Massachusetts is one of the healthiest states to live in and obtain health coverage. The state has continued to stay in its top ten slots as it took the 7th and 9th spot in 2006 and 2007 respectively. Several factors have contributed to the state’s strong healthcare system including increased public health funding and low percentage of residents lacking health insurance. The state of Massachusetts, with more than six million people, offers both private-market and public health insurance alternatives. The private-market health insurance consists of various types of health plans including family, Medicare supplemental, short-term, student, group and dental. Additionally, the state and federal government sponsored programs provide low-priced coverage to the uninsurable residents of Massachusetts who meet specific eligibility requirements of age and income.

The Massachusetts Division of Insurance manages and supervises all kinds of insurance sold through private-market health insurers as well as public health coverage programs. However, the population surviving without insurance is quite low i.e. approximately 7.9%. According to the Censor Bureau’s 2007 and 2008 Current Population Survey, roughly 41.9% of Massachusetts’s uninsured residents come under the above 200% FPL category.

Buying health coverage can often be intimidating. Nevertheless, through a licensed health insurance agent/broker, you can choose a proper health insurance plan with benefits that are ideal for you and your family.

Individual/Family Health Insurance

Below is the guidelines for applying for and obtaining individual health insurance in the state of Massachusetts. These regulations apply to all insurance companies offering individual or family health insurance in Massachusetts:

Medical Underwriting


Pre-Existing Condition Exclusion Period

6 months

Look Back Period

6 months

Look Back Standard


Mandatory Benefits

Cancer screening for women including screening of breast and cervical cancer, direct access to OB/GYNs, eating disorder parity, infertility coverage, maternity coverage

Market Rate Restrictions


Guaranteed Issue Options


Small Group Health Insurance

Below is the guidelines for small group health insurance in the state of Massachusetts. These regulations apply to all insurance companies offering small group health insurance in Massachusetts.

Small Group Size


Employee Qualifications

A full-time employee is:

Someone who works 35 hours or more per week at a Massachusetts location (5even if they live in another state).

A full-time employee is not: 1) Independent contractors 2) Seasonal employees. 3) Temporary employees are not considered full-time employees. 4) Workers from temp agencies (5they are the temp agency’s employees).

Guaranteed Issue


Premium Rating Factors

Adjusted Community Rating

Rate Adjustment Factors

Look-Back Period

6 months

Pre-existing condition exclusionary period

6 months

Mandatory Benefits

Same as individual

State Cobra Variations for Small Groups

Below are the COBRA guidelines for small groups in the state of Massachusetts. For employer groups of more than 20 employees, refer to the federal COBRA guidelines:

Mini-Cobra Option


Eligible Group Sizes


Extension of Benefits Period – Standard

18 months

Extension of Benefits Period – Disabled

18 months

Maximum Premium Increase


State Legislation Reference

Chapter 176, Section 9 of 22 – Small Group Health Insurance/Continuation of Coverage

Additional Notes

Continued coverage under the employer’s group plan is provided to any individual that has been insured under the group’s policy for at least 39 weeks. If prior coverage was less than 39 weeks, continuation rights must equal the length of time that individual was insured under the group plan.

State Sponsored Health Insurance Programs

There are several state sponsored health insurance programs in the State of Massachusetts to assist those without insurance in obtaining adequate coverage.

High-Risk Pools

Some states offer special state sponsored health insurance plans for qualified persons that are not eligible for individual health insurance due to pre-existing medical conditions. However, Massachusetts does not offer health insurance coverage through state high risk pool program for individuals who are medically-uninsurable.

Children’s Health Insurance Program

Through shared funding from the federal government, the State of Massachusetts provides health insurance for uninsured children that meet certain eligibility guidelines. A summary of this program is outlined in the chart below:

Program Name

Children’s Medical Security Plan (5CMSP)



Phone Number


Apply Online


Age Limits

Under 19

Insurance Carrier


Length of Coverage

12 months

Residency Requirements

Massachusetts resident

Other Eligibility Requirements

Coverage is provided to children who do not qualify for any other MassHealth coverage type (5except MassHealth Limited), and who do not have physician and hospital health-care coverage.

Pre-Existing Condition Exclusions



Depending on your income costs will vary (5Premiums between $0-38.99 per child; Co-pays $2-8, Pharmacy $3-4)


Medicaid is a state program partially funded through the federal government. Qualification guidelines, as well as the types of people that are eligible, will vary by state. The chart below provides a summary of the Medicaid programs in the State of Massachusetts:

Governing Agency

Office of Health and Human Services



Phone Number


Residency Requirements

Massachusetts resident and U.S. citizen, legal immigrants undocumented immigrants,

Federal Poverty Line Income Limits

Additional Resources

Massachusetts Health Care Options Matrix™ Guide

Provided by the Foundation for Health Coverage Education, the guide is a quick reference guide prepared by the non-profit Foundation for Health Coverage Education that outlines Massachusetts’s public and private health care choices for individuals and groups with various demographic profiles.

Family Health Insurance Guide by

The guide created by provides useful information regarding health insurance coverage such as individual/family health insurance, group health insurance, separate child health insurance and state-sponsored programs that are available for low to middle income families.

Massachusetts: At-A-Glance

Provides exclusive health data of Massachusetts. is a project of the Henry J. Kaiser Family Foundation and is designed to provide free, up-to-date, and easy-to-use health data on all 50 states.