How do I find out if I have enough health coverage according to MA state law?
Your insurance carrier has the information. In fact, you should receive a letter from your carrier each year verifying whether or not your insurance coverage is in compliance with MA state law.
Will I be fined for not having health insurance?
Massachusetts law requires that all residents have health insurance, and you may face tax penalties if you are uninsured or your insurance coverage does not meet state coverage standards. For more information on the penalty you can contact the Department of Revenue (DOR) at 800-392-6089.
Can my health insurance be cancelled?
In Massachusetts your health insurance can only be cancelled for non-payment of premium or fraud.
How long do I have to pay my insurance premium once I receive a letter of cancellation due to non-payment of my premium?
You usually have 30 days to make good on unpaid premiums before policies can be cancelled. You should contact your insurance company to find out if there are ways to make arrangements to pay the overdue premium over a period of time.
Can I cancel my own health insurance?
It is not advisable to cancel your health insurance coverage unless you have alternative coverage lined up that meets minimum creditable coverage standards. You should also keep in mind that individuals can only enroll in a new health plan during the regular annual open enrollment period each fall or through a special enrollment process if you have experienced some type of qualifying event (for instance, you just moved to Massachusetts or you are getting divorced and losing coverage from your spouse’s employer).
If you are enrolled in a health plan through MassHealth or the HealthConnector and need to cancel it because you are now eligible for employer-sponsored coverage, you should contact MassHealth or the HealthConnector directly to disenroll. You will want to keep in mind when your new coverage is expected to begin so that you do not overlap or go without coverage. If you are changing jobs, were laid off or terminated, or retiring, your employer will generally handle cancelling your health insurance coverage.
The insurance company is requiring that I provide them my Social Security number in order to apply for health coverage. Why does the insurance company need my Social Security number?
Federal regulations governing the Internal Revenue Service (IRS) require that all health insurance carriers that provide minimum essential coverage to an individual during a calendar year must report to the IRS the name and Social Security number (SSN) of each individual who is covered under the policy or program. Learn more about this requirement here: https://www.irs.gov/affordable-care-act/questions-and-answers-about-reporting-social-security-numbers-to-your-health-insurance-company.
Your SSN should only be asked for by the company that you are buying insurance from when you are filling out the application for insurance. Never provide a SSN while shopping for insurance or comparing premiums.
Both state and federal law require that your personal information must be kept confidential and cannot be shared or misused. For more information on how Massachusetts law defines personally identifiable information and what steps businesses must take to protect that personal information, please visit https://www.mass.gov/identity-theft-data-privacy-and-cyber-security.
What information can the insurance company ask of me when I’m shopping for insurance?
Very little. In order to send you quotes, they need to know your name, age, and contact information and whether you are looking for coverage for just yourself or if you have family members who would also be covered by the plan. However, they cannot ask questions about your medical history, such as whether you have pre-existing conditions or what prescriptions that you might be taking. If you apply for insurance on the Massachusetts Health Connector website: https://www.mahealthconnector.org/help-center, you may be asked whether you would like to provide financial information that could assist the Connector in helping you determine whether you may be eligible for financial subsidies that may help you pay for your insurance.
What is HIPAA?
The Health Information Portability and Accountability Act (HIPAA) provides protection for privacy of personal health information, while ensuring that information is available, as needed, to provide health services to those in need. Title I protects health insurance coverage for workers and their families when they change or lose jobs. Title II establishes national standards for electronic health care transactions and national identification information for providers, health insurance companies, and employers.
Can my employer change our health insurance carrier and the level of benefits we get during the year?
Yes. They may change carriers and benefits at any time. If you have any questions about how your employer is administering your health options, you may call the federal Department of Labor at (857) 264-4600.
My child turned 26 years old and can no longer be covered on my insurance plan. What should they do?
They have 60 days from the date the coverage ends to purchase a new policy or face penalties. For information on how to find the plan that works best for them, visit: https://www.mass.gov/info-details/health-insurance-plans-which-plan-is-right-for-you.
Are lifetime limits on health benefits legal?
Massachusetts law prohibits insurance companies from imposing lifetime dollar limits on major medical health insurance benefits.
What is meant by “Medical Necessity?”
Medical necessity means health care services that are consistent with the generally accepted principles of professional medical practice as determined by whether the service:
- Is the most appropriate available supply or level of service for the insured in question, considering potential benefits and harms to the individual;
- Is known to be effective in improving health outcomes, based on scientific evidence, professional standards, and expert opinion; or
- Can be justified for use based on scientific evidence.
How is “medical necessity” determined? A doctor’s attestation that a service is medically necessary is an important consideration. Your doctor or other provider may be asked to provide a “Letter of Medical Necessity” to your health plan as part of a “certification” or “utilization review” process. This process allows the health plan to review requested medical services to determine whether there is coverage for the requested service.
Emergency services may be reviewed retrospectively to see if the care was appropriate to your diagnosis and medically necessary for an emergency level of care. The standard for making this coverage decision is made on the “prudent layperson” standard, which allows that a precertification is not necessary if a prudent layperson would believe that an emergency condition existed and that a delay in treatment would worsen that condition.
The DOI cannot make medical necessity determinations. If your claim is denied and your insurer states that lack of medical necessity is the reason, you can file an internal appeal with the insurer. If the insurer denies your appeal, you can request an external review through the Massachusetts Office of Patient Protection (OPP).
Some definitions of medical necessity include the requirement that they are “not for experimental, investigational or cosmetic purposes”. Health plans may use their medical policies to determine if a treatment is considered experimental for your condition. Services and treatments that are considered experimental, investigational, or cosmetic may also be appealed to OPP.
Additional Resources for
Is coverage of mental health and substance use disorder (MH/SUD) services required in MA?
Yes, this type of coverage is required for all fully-insured major medical plans offered to large groups, small groups, individuals, and students.
My plan is ‘self-insured’. What does that mean?
Some employers do not use a traditional insurance plan to provide health insurance to their employees. Rather than paying a premium to an insurance company to insure their employees, employers will instead pay for employee healthcare costs directly, but they may use an insurance company to help process the paperwork. The insurance company is acting as a third party administrator to help with paperwork. This is a called a self-insured or self-funded plan. The Massachusetts Division of Insurance does not have jurisdiction over self-insured plans; the federal government through the Department of Labor does have jurisdiction over many of these plans. Your employer/HR department or plan administrator will be able to tell you if your plan is self-funded.
According to my divorce decree, my ex-spouse is required to provide my health insurance. Does the health insurer have to permit that?
Does the employer who sponsors the plan have to permit that? Can my ex-spouse remove me from his/her health insurance without my permission? If so, does the health insurer have to notify me that my coverage has been canceled?
In most instances, if a judge has ordered your spouse to continue to carry you on his/her fully insured health insurance, the health insurer and/or the employer need to abide by this judgment. Generally, the law only applies if the employer’s health plan does not change. If you remarry, you may wish to consult with an attorney to review whether the judgment still applies or if you need to find alternate health insurance.
How long does my health insurer have to either pay or deny my claim?
Massachusetts law requires that insurance companies affirm or deny coverage of claims within a reasonable time. While there is no standard time frame, your provider submits the claim within the time frame established in their contract with the insurance company and then the insurer makes a decision of denial or payment of the claim. If the insurance company is being unresponsive, you can file a complaint with the DOI.
I have two health insurance plans. Which is primary?
It depends on what the two plans/products are, and what services are being sought. If you have two insurance plans, you should consult with your insurance companies to help determine which is primary.
Does my health insurance plan include prescription drug benefits?
Most health plans help pay the cost of covered prescription drugs. Insurers often use a “formulary” that lists what medicines will be covered and how much of the cost you’ll pay. If you need a specific prescription, you should review your plan’s formulary, which is a listing of what medications are covered, to learn if the drug is covered. A formulary usually has different tiers based on the type of covered medicine. Prescription medicines listed in one tier may cost you more than those in another tier (ie: specialty or non-preferred brands vs generics). You may have to pay the full cost of prescription medicines until you reach your plan’s deductible for the year. Prescriptions that you pay for will count toward your annual out-of-pocket maximum.
You can ask your insurance company for an exception if a drug you need is not on your plan’s formulary. If the insurance company denies your request, you may be able to file a medical necessity appeal to the Office of Patent Protection.
Many drug manufacturers also offer discounts if you are having difficulty paying for your prescription.