- Office of Consumer Affairs and Business Regulation
The Open Enrollment period for obtaining health insurance coverage from the Massachusetts Health Connector for 2019 is November 1, 2018 through January 23, 2019. Open Enrollment is the only period of time that Massachusetts and federal law permit individual consumers to purchase an insured health plan, unless there is a qualifying event, such as a birth or adoption of a child, marriage, divorce, loss of insurance through employer, etc.
Most Americans participate in group health insurance plans offered by their employer or through public programs such as Medicare and Medicaid. For those residents who purchase health insurance on their own through the Connector Marketplace, keep in mind:
- There is still a penalty in MA for not having minimum essential coverage. There continue to be Massachusetts rules that require residents to have a certain health insurance coverages.
- More direct enrollment options are available. Consumers can enroll in the healthcare exchange marketplaces or through insurance carriers’ own websites. The new direct enrollment option allows agents to handle the entire transaction. Compare plans before buying to understand all choices.
If you are satisfied with your insured health plan and its benefits, you don’t need to do anything during the Open Enrollment period. However, if you are exploring a new insurance plan, here are some things to consider:
- Read and understand the materials. There are many different types of health plans offered in Massachusetts, such as Preferred Provider Plans (PPP), Health Maintenance Organizations (HMO), and Indemnity plans. Before making a choice, be sure to check if a plan has a provider network and whether your current physicians and area hospitals are in it. If a plan does offer benefits through a network, the plan will detail those medical providers (physicians, hospitals, labs, pharmacies, etc.) that are considered in-network and out-of-network. Some plans, such as HMOs, will not pay for any services outside of the provider network. Other plans, such as PPPs, offer benefits with lower cost-sharing if care is received by providers in their preferred network. You should be aware of all potential charges before seeing an out-of-network provider, since out-of-network providers can balance bill you up to the entire billed amount of the medical service. In contrast, in-network providers must accept the rate they have negotiated with the carrier as their payment in full. There may be member cost sharing associated with network providers, such as deductibles, copays, and coinsurance costs, but in-network providers for fully insured Massachusetts plans cannot require insured health plan members to pay more than the rate the provider negotiated with the health insurance plan.
- Some plans assign network providers to benefit tiers within their network. Review the benefit tier your current physicians and area hospitals are in, because the amount you pay to see a provider will depend on which tier that provider is in. Make sure you understand any difference in benefits for network providers according to the tier to which the provider has been assigned.
- Compare health plan costs and coverages. It is important to carefully evaluate your healthcare costs when making your annual enrollment decisions. One plan might have high monthly premiums and a low deductible, while another might have a low premium, but more out-of-pocket expenses.
- To help pick the best coverage, calculate your healthcare costs from recent years and try to estimate what your costs might be for the coming year. Don’t forget to include the cost of doctor visits, daily medication, and any procedures you might be planning. Then make a list of the premiums, out-of-pocket expenses and benefits under each plan. Co-payments, coinsurance, deductibles, and additional charges for wellness care or certain services, such as alternative medicine and cosmetic surgery, are examples of out-of-pocket expenses that you may pay. Remember, if you use a provider that is out-of-network, you will generally pay more out-of-pocket expenses. Add those fees to your calculated costs. Finally, decide how much you can afford to pay.
Remember: Once enrolled in a health plan, you will not be able to make changes until the next Open Enrollment, unless there is a qualifying event. If you do not receive insurance cards and/or enrollment information, contact your insurance company. More online resources can be found at the Division of Insurance’s online consumer guide to health care coverage.
