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Health Care Coverage

The Patient Protection and
Affordable Care Act of 2010

 

 

Sections:

 

The ACA and Paying Taxes

For a tax assister and a guide for 2015 tax season filing as it relates to health insurance see Taxes (on our Financial Assistance page).

 

Open Enrollment

Massachusetts: Open Enrollment period is generally November 1 to January 23 for coverage beginning the following month. States who run their own exchanges have some discretion in the length of Open Enrollment- Here's NPR's list of the other 10 states plus the District of Columbia that run their own ACA sites and marketplaces.

Those seeking financial assistance for coverage, those experiencing a qualifying life event and those applying for dental coverage may apply at any time. See below.

 

Regular Enrollment Details:

Consumers are encouraged to update their applications with the most current information and browse their plan options. Members can remain in their same plan for the following year, if that plan is available, but if not, then members will be mapped into a similar plan. Unless a member checks out with a new plan, they will be auto-renewed into their mapped plan in late November.  Members can always shop for a new plan until the end of Open Enrollment (until 12/23 for coverage starting 1/1, 1/23 for 2/1, and 1/31 for 3/1).

Those seeking financial assistance for insurance coverage can apply at any time during the year. Those ineligible for subsidies must have a qualifying life event to purchase coverage outside of open enrollment. Details:

  • Applicants determined eligible for ConnectorCare, MassHealth, the Children's Medical Security Program, or Health Safety Net, will be able to enroll in that coverage at any time during the year.
  • Applicants only determined eligible for tax credits or determined not to be eligible for any help paying for the cost of their health insurance, must have a qualifying event that allows them to shop before the next open enrollment period.
  • Dental insurance - available year round for purchase.
  • Note also-those found eligible for ConnnectorCare during open enrollmentand still within 60 days of date on eligibility notice have until 60th day to enroll. (For example, applied & found eligible Jan 29, have until March 29, to enroll).

Qualifying Life Events

Qualifying Life Events allow those who do not qualify for ConnectorCare, MassHealth, the Children's Medical Security Program, or Health Safety Net to buy insurance outside of Open Enrollment. See link for details, but qualifying life events include (NOT a complete list):

  • Marriage
  • Birth or adoption of child
  • Loss of coverage for a variety of reasons (does not include loss due to failure to pay premiums)
  • Move
  • Victim of domestic abuse or spousal abandonment
  • See full list

Problems with an application? Contact the Connector's Ombudsman.

 

Overview/Key Points

 

  • New! ACA to Expand to More Families - Biden Administration addressing the "family glitch"
    • President Biden is making a tweak to federal rules long sought by advocates that would allow millions of additional families to buy health plans through the insurance marketplaces created under the Affordable Care Act.

      The tweak involves what is known in health-policy circles as the ACA’s “family glitch.” For the most part, ACA marketplaces are open to U.S. residents who do not have access to health benefits through a job. However, the law also contains a provision that lets people buy ACA health plans even if they have a job that offers health benefits if monthly premiums would require them to spend roughly 10 percent or more of their household income on that coverage.

      The wrinkle has been that, in calculating how big a bite an employers’ health plan would take out of a worker’s income, the amount has taken into account only the premiums for an individual insurance policy — not a policy that covers a workers’ spouse or children, too. (4/22) More information.

  • MA ACA Subsidized Health Coverage Landscape


    • Graphic depiction of what populations get what coverage in MA under the ACA

    Glossary
    QHP= Qualified Health Plan
    AWSS= Aliens with Special Status (legally present, but not MassHealth eligible such as subject to the 5-year bar)

    The Basics

    • Affordable Care Act applies primarily to the UNDER 65 population. (A few elder provisions such as helping close the Medicare D Donut Hole over next few years.)

    • Open Enrollment- Open enrollment for typically runs from November through January 23rd.
      • Those seeking financial assistance for insurance coverage can apply at any time during the year.
        • If they are determined eligible for ConnectorCare, MassHealth, the Children's Medical Security Program, or Health Safety Net, they will be able to enroll in that coverage at any time during the year.
        • If they are only determined eligible for tax credits or are determined not to be eligible for any help paying for the cost of their health insurance, they must have a qualifying event that allows them to shop before the next open enrollment period.
        • Dental insurance - available year round for purchase.

      Subsidized Coverage

      • Medicaid Expansion- Massachusetts has expanded Medicaid eligibility (MassHealth in MA). Formerly to qualify one had to meet categorical eligibility requirements- elderly, child, parent or disabled (or a few other very limited categories). Now low-income people, regardless of membership in a category, may qualify. So, for example, able-bodied low-income adults may qualify for the first time.
        • Those in one of the key categories may still qualify at higher incomes. See chart (but remember to use Modified Adjusted Gross Income [MAGI] to determine eligibility for those under 65).
        • Increased income limits for 19-20 year olds- 19- and 20-year-olds with incomes up to 150 percent FPL will be considered children under MassHealth, will receive MassHealth Standard benefits, and will be exempt from co-payments. Previously, MassHealth defined children as ages zero to 18; 19 & 20 year olds were subject to the adult 133% FPL income limit. (Parents are still defined as parents living with children under age 19, and 19- and 20-year-olds with income over 150 percent FPL will not be able to qualify for Family Assistance as children.)
        • Former Foster Children eligible up to age 26 - former foster care children up to age 26 are now eligible for MassHealth Standard regardless of income. Previously this group was only eligible based on foster child status up to age 21.
        • Pregnant undocumented women will now be eligible for MassHealth Standard for the duration of their pregnancy. (Eligibility, once established, continues for the duration of the pregnancy. Eligibility for postpartum care continues for 60 days following the termination of the pregnancy plus an additional period extending to the end of the month in which the 60-day period ends.)
        • New Coverage Type: MassHealth CarePlus - Most in these expansion categories will be assigned to CarePlus. Those formerly in MassHealth Essential and MassHealth Basic will also be assigned to CarePlus as those coverage types will be eliminated.
          • CarePlus advocacy tips:
            • CarePlus offers enhanced benefits over it predecessor programs Basic and Essential. Enhanced benefits include hospice and non-emergency transportation (PT-1)
            • "Medically Frail" certain people with significant health and/or mental health needs may be able to opt in to MassHealth Standard.

         

      • Commonwealth Care becomes ConnectorCare- ConnectorCare is for those with income between 100% and 300% FPL (Commonwealth Care's income limit was also 300% FPL). A combination of state and federal subsidies helps ensure that benefits and patient costs under ConnectorCare plans are similar or better than under Commonwealth Care.
        • The 100% FPL floor was not initially applied; it has been in effect since summer 2015. Most people with income below 100% FPL will be eligible for MassHealth. There is an exception for those immigrants who are barred from MassHealth due to immigration status (e.g., legal residents during the 5 year bar)- they can get ConnectorCare with income less than 100% FPL. There is a group of people who will NOT qualify for coverage under either program under this rule; mainly seniors, they are excluded by the ConnectorCare floor and don't qualify for MassHealth because MassHealth counts assets for seniors and theirs exceed MassHealth limits. (More information.)
        • ConnectorCare will use 2015 FPLs to determine eligibility until the next Open Enrollment period for coverage in 2017. See page 2 of chart.
        • Those with Access to Employer Sponsored Insurance May Be Eligible for ConnectorCare. To buy any plan through The Connector one must meet Health Insurance Marketplace requirements: must be a U.S. citizen or lawful resident, not incarcerated, and a resident of the state in which the Health Insurance Marketplace is operating. People with access to employer-sponsored insurance (ESI) that is “unaffordable"* will, if otherwise eligible, be eligible for ConnectorCare. Most people with access to ESI, even if unaffordable, were not eligible for the Commonwealth Care program.
          • *Affordability: According to federal rules, employer-based coverage is affordable if a worker's share of the monthly premium for an individual plan is not greater than 9.5% of the worker's income. So, if the cost is greater than 9.5% of the worker's income, he/she may be eligible for ConnectorCare.
            • The cost of a family plan, which is much higher than the cost of an individual plan, is not taken into account. Massachusetts may offer state subsidies to help families who do not qualify for federal assistance based on the cost of an individual plan, but cannot afford the higher cost of employer-based family coverage.
              (Affordability definitions from:  http://www.massresources.org/health-care-2014.html#qhps.)
            • Affordability rules may lead to a "subsidy gap"- The calculation is not as simple as being under a certain income level; subsidies kick in only when a baseline health plan exceeds a certain percentage of a person's income. The higher a person's income, the more expensive premiums must be before subsidies kick in. (The Health Insurance Subsidy Gap, MGH Community News, March 2014).

       

      • New Subsidies available for those between 300% & 400% FPL- the ACA provides for federal subsidies up to 400% FPL. Under the state's health reform that created Commonwealth Care (now ConnectorCare- see above) subsidies were only available up to 300% FPL. Those in between 300% and 400% FPL can buy Qualified Health Plans (QHPs) through The Connector - the state's insurance exchange with a federal subsidy.
        • Affordability rules may lead to a "subsidy gap"- The calculation is not as simple as being under a certain income level; subsidies kick in only when a baseline health plan exceeds a certain percentage of a person's income. The higher a person's income, the more expensive premiums must be before subsidies kick in. (The Health Insurance Subsidy Gap, MGH Community News, March 2014).
        • Note: QHPs will use 2014 FPLs to determine eligibility until the next Open Enrollment period (November 2015) for coverage in 2016. See page 2 of chart.)

       

      • Federal subsidies are provided in the form of advanced premium tax credits that are either paid directly to the insurer or one can opt to receive them instead as a credit when one files taxes. To qualify for these subsidies on plans purchased through the exchanges, one must file taxes. If someone has never filed taxes before that will not be a block to getting tax credits as long as the person attests that he or she will file taxes for the year in which tax credits are given.  Married applicants must file a joint return for the year in which they receive these tax credits.
        • Reconciliation- All receiving tax credits should report any changes in income, household configuration and filing status promptly. Tax credits are determined based on projected estimates of income, household composition and tax filing status for the year in which one will be receiving benefits. Those receiving tax credits will be subject to reconciliation after filing their taxes for a year in which they received tax credits. The tax credit will be recalculated based on actual income, household composition, etc. Individuals may be found to be entitled to a higher refund than expected, or may be required to pay back any tax credits they received that they were not entitled to.

       

      • COBRA and ConnectorCare- If you decide not to take COBRA coverage, you can enroll in a Marketplace plan instead. Losing job-based coverage qualifies you for a Special Enrollment Period (SEP). This means you have 60 days to enroll in a health plan, even if it’s outside the annual Open Enrollment Period. (Learn more about qualifying life events that trigger a SEP.) For more on options if you already have COBRA and want to switch to ConnectorCare (or other Marketplace plan in other states).

      • Health Safety Net (HSN) and ConnectorCare- Effective June 1, 2016, households determined eligible for ConnectorCare lose HSN eligibility after 90 days, except for dental coverage. In other words those eligible for both program shave 90 days to select and enroll in a ConnectorCare plan. At the end of the 90 days, these individuals are eligible to use the HSN for HSN-eligible dental services only. It is important that those eligible for ConnectorCare enroll in a ConnectorCare plan as soon as possible so they do not experience a gap in coverage. Individuals can enroll in a ConnectorCare plan by going to www.MAhealthconnector.org. Individuals will need to select a plan and make their first month's premium payment, if they have one. Questions about the Health Safety Net may be directed Patient Financial Services or to the HSN Help Desk at 1-877-910-2100. 

      • Program Consolidation- Some state programs have been eliminated as similar or better coverage will now be available. Programs being eliminated include the Medical Security Plan (health coverage for those receiving Unemployment Compensation), Healthy Start and the Insurance Partnership.

      • Immigrants:
        • Key resource: Understanding the Affordable Care Act in MA: Eligibility of non-citizens for MassHealth & other subsidized health benefits (10/15)
        • Legal Immigrants- Those under the 5 year bar or with another legal status that as a result of that status are ineligible for MassHealth may qualify for ConnectorCare or to Purchase QHPs depending on income.
          • Note: legal immigrant children are afforded greater access to health care coverage than adults. Those under the 5 year bar for example may be eligible for MassHealth Standard or MassHealth Family Assistance depending on income.
        • Undocumented Immigrants- low-income undocumented immigrants are not eligible for MassHealth (except for MassHealth Limited, or pregnant women under 200% FPL who may be eligible for Standard during their pregnancy and for postpartum care). They may be eligible for HSN. They are not eligible to purchase plans through the state exchange/The Connector. They may be able to purchase plans through an employer or directly from the insurer.
        • Visa Holders- these cases should be referred to Patient Financial Services. Those with work visas or student visas for example may be able to purchase insurance through The Connector. If applicants/members provide a copy of a visa, but indicate on the application that they are not a visitor they may be considered residents of the Commonwealth if they currently live in MA and intend to stay.
          • Details/Background:
            • Under the federal law's immigration provisions those with "work" or "student" visas would be eligible to purchase and for subsidies, however, another requirement to purchase through The Connector (or any exchange) is state residency.
              • According to the state's Member booklet (covering MassHealth, the Children’s Medical Security Plan [CMSP], ConnectorCare Plans and Premium Tax Credits, and the Health Safety Net), an individual’s residency will be considered proven if the individual has self-declared to being a Massachusetts resident, and the residency has been confirmed by electronic data matching with federal or state agencies, OR the individual has provided any of the following documents (see member booklet p 7 for complete list):
                • A current utility bill or work order dated within the past 60 days
                • A statement from a homeless shelter or homeless service provider
                • Proof of enrollment of custodial dependent in public school
                • A copy of the lease AND record of the most recent rent payment
                • If you cannot give us any of the documents listed above, you may submit an affidavit supporting residency signed under the pains and penalties of perjury.
              • Note: MassHealth explicitly excludes from state residency those who "came to Massachusetts for the purpose of receiving medical care in a setting other than a nursing facility, and who maintain a residence outside of Massachusetts". (Sec 503.002 (G)(1))
        • More information:

       

    • Unsubsidized/Market-Rate Coverage

      • Qualified Health Plans (QHPs) are also available through The Connector without a subsidy for those with income above 400% FPL.

      • Non-Group Coverage Outside The Connector- Previously in Massachusetts, an individual could only purchase non-group coverage (inside or outside the Health Connector) if he or she did not have access to employer-sponsored insurance that met the state’s Minimum Creditable Coverage standards. To comply with the ACA, the state has changed its laws to allow any resident of Massachusetts to purchase non-group coverage. To buy any plan through The Connector one must meet Health Insurance Marketplace requirements (must be a U.S. citizen or lawful resident, not incarcerated, and a resident of the state in which the Health Insurance Marketplace is operating). MA residents who do not meet these criteria may purchase coverage outside the Connector.
        • Undocumented immigrants for example, cannot purchase insurance through The Connector, but may purchase through an employer or directly from the insurer.

 

Reference Materials/More Information

Special Topic - Young Adults (for details see our Young Adults Health Care Coverage page)
  • Young Adults up to age 26 can stay on their parent's insurance plan
  • Catastrophic Plans- People under 30 and people with hardship exemptions may buy a "catastrophic" health plan.
  • College Students- Under the Affordable Care Act the state is no longer allowed to exclude from subsidized programs those who can get insurance elsewhere, and that includes college students. Colleges are now required to accept plans from the Connector or MassHealth, with a few rare exceptions.
  • More information: see our Young Adults Health Care Coverage page

    • Special Topic- Pediatric Dental Coverage

    • Though pediatric dental coverage is technically mandated, there are no penalties for families who do not purchase it.
    • Because some plans in the marketplace include embedded pediatric dental coverage, while other plans require that coverage be purchased separately, there exists an underlying confusion and inconsistency. (Adult dental benefits always have to be purchased separately — because they're optional, under the law.)
    • Because stand-alone dental plans are not eligible for federally-sponsored subsidies, families face an economic disincentive to buy such plans—and the most vulnerable families (namely those with particularly tight budgets) may not be able to afford them at all.
    • Learn more

    Special Topic - Medicare Eligibility Ends Medicaid Expansion Eligibility

    • Under the Affordable Care Act (ACA), states can expand Medicaid coverage to adults ages 19-64 earning up to 138% of the Federal Poverty Level (FPL). To date, 28 states and the District of Columbia have chosen to expand the program.

      Individuals enrolled in expansion Medicaid have little or no out-of-pocket costs when accessing covered health care, prescription medications, and other Medicaid-covered services, and these individuals rarely pay a premium. When a person turns 65 or becomes eligible for Medicare under the age of 65, however, that person generally can no longer qualify for expansion Medicaid and must instead be covered under Medicare. Eligibility for full Medicaid benefits are often stricter and can count a person’s assets, whereas assets are not counted to determine eligibility for expansion Medicaid.

      An important outreach/advocacy opportunity is to ensure that those eligible are aware of the Medicare Savings Programs (MSPs), all of which pay a Medicare beneficiary’s Part B premium, and automatically qualify that individual for assistance with Medicare prescription drug costs, through the Extra Help program. One of the MSPs also helps with other out of pocket costs. Unfortunately MSPs in most states also set asset limits (though higher than for Medicaid eligibility).

      See the AARP Public Policy Institute report.

      Additional Medicare note- Medicare B: One-Time Special Enrollment Period (SEP) for Those Who Did Not Take Medicare B Thinking They Could Get Marketplace Subsidy

      Many people newly eligible for Medicare thought it would be cheaper to remain in the Marketplace with subsidies, rather than pay Part B premiums, but did not realize that their Medicare Part A eligibility made them ineligible for premium subsidies, also called Advance Premium Tax Credits (APTC). When they realized their mistake, they were past their initial enrollment period and could only enroll in Part B during a General Enrollment Period, often incurring Part B late enrollment penalties.

      For a limited time, these individuals were able to apply for equitable relief that gave them a Special Enrollment Period (SEP) to enroll in Part B and Part B late enrollment penalties did not apply. The application deadline for this SEP WAS March 31, 2017.

      Learn more.

    Other Topics/ACA in the News

Older articles:

     

     

    The 2014 Transition Period from Mass Plan to Full ACA Compliance

    • Applying:
      Learn more about Open Enrollment.
      • MGH patients should apply through Patient Financial Services.
      • Non-MGH applicants can call 1-877-MA-ENROLL (1-877-623-6765), TTY 1-877-623-7773 or visit a Connector office: 133 Portland Street, 1st Floor, Boston or 146 Main Street, Suite 201/202, Worcester. Or see The Connector's website for local Health Connector Navigators or Certified Application Counselors. Or see the Contact List (phone & fax).
      • More: State Health Connector Website Woes Continue (February 2014)
      • See more (older) coverage on The Boston Globe coverage of The Connector's website woes.

    • Massachusetts Temporary Health Coverage- due to ongoing problems with the state's health care coverage website, the state offered temporary MassHealth coverage to those applying for subsidized coverage while the state could not process their application. By now members should all have transitioned to other forms of coverage.

    • ACA Transition Provider Toolkit-
      • Guide to determine whether a person who is currently enrolled in some form of subsidized health coverage may experience a change in coverage under the Affordable Care Act transition. It will tell you what coverage they will likely transition to, and whether he or she should be automatically moved to a new program, needs to re-apply or will experience no change.

    • PHS-Specific Materials
      • PHS Transition Guide - grid that explains what coverage individuals will transition to, whether they need to actively apply, and what coverage they should select if they wish to continue to receive care at MGH/Partners.
        • Post Transition: PHS ACA Transition for 1/1/14: State Health Insurance Programs you may see (valid through 3/31/14.) - a tool that explains each category, the plans we accept, and how you should be directing patients in that group.  
        • Continuity of Care- MassHealth CarePlus- Many of our patients have been auto-assigned to a MassHealth CarePlus plan that we do not accept (for MGH this means anything other than NHP).  Patients may switch plans, but the change does not take effect until the first of the month. The health plans MUST allow CarePlus patients assigned to plans not accepted by their current providers to continue care for 30 days after auto-assignment.  (Applies to existing pts only. we cannot accept new pts.) 
          • This does NOT apply to Network Health Medicaid patients who are NOT CarePlus and just never switched their plan.  They can switch plans anytime if they want to continue to come to us for care.
          • Most of the patients who need to take advantage of this will be CeltiCare patients.  CeltiCare’s process is as follows:
            • In the first 30 days after auto-assignment, members can see non-participating specialists and PCPs without a special prior authorization
            • After 30 days, they would need a “Transition of Care Auth” to continue services unless the member changes their plan
            • All services that would normally need an authorization would need to have a prior authorization even in the first 30 days
          • We assume the process will work similarly with our other non-contracted CarePlus plans like Network Health and BMC HealthNet, but will pass along further details if they become available.

2010 Materials

Law Summary- MGH Community News, March 2010

Components of Law & Special Issues

Opinion on the Affordable Care Act