Your Right to Obtain Health Insurance in Massachusetts

Health insurance is almost entirely regulated by the states, and the rules and regulations governing it vary widely from one state to another, permitting or disallowing barriers to access.  It is important to understand how health insurance functions in your state in order to evaluate what types of reform are needed, both on the state and federal level, to make quality, affordable health insurance available to everyone.

Your rights to obtain health insurance in Massachusetts vary depending on whether you purchase insurance as an individual, under a group plan, or as a small business owner.

Getting health insurance as an individual in the open market

In Massachusetts, all adults (over 18) are required to have health insurance. You cannot be denied insurance or charged more because of your health status, age, gender, or occupation. If you do not receive insurance from an employer, you can purchase a plan from an insurance company, or you can buy insurance from the Commonwealth Health Connector, a state agency that helps residents purchase insurance plans.
Insurers can however count as pre-existing conditions those for which you received medical advice in the 6 months prior to the start of your policy. If you had a break in insurance coverage of 63 days or more, you may face a pre-existing condition exclusion period. Coverage for pre-existing conditions can be excluded for a maximum of 6 months. Insurers can also impose a waiting period for up to the first four months of your coverage.  During the waiting period, the plan will only pay for emergency services. If you did not have a break in your insurance of 63 days or more, insurance companies must waive or reduce the time of these limits.

COBRA is a law that lets you keep the insurance you had through an employer or union for up to 18 months (sometimes longer) after you’ve left your job or become ineligible for benefits. You will pay the full premium, i.e. both your share and the amount your employer or union was paying on your behalf. Although you may be able to continue your group coverage via COBRA, you are still able to purchase directly from an insurance company or through the Connector.

Getting insurance through a group or small business

If you are insured through your employer, union, or some other type of group, you cannot be denied insurance because of your medical history. Insurers can however count as pre-existing conditions those for which you received medical advice in the 6 months prior to the start of your policy. If you had a break in insurance coverage of 63 days or more, you may face a pre-existing condition exclusion period. Coverage for pre-existing conditions can be excluded for a maximum of 6 months.
If you are self-employed with no other workers, you are eligible to buy a group health plan on your own. However, certain exclusions and stipulations may apply. Please contact Massachusetts’s Department of Insurance for more information on your rights as a sole proprietor.

For more information on getting and keeping health insurance, please visit www.ahirc.org.