Health Care Options (This page was updated on 10/21/11)
This is a listing and explanation of some of the health care programs available. We have highlighted the ones that are most common and will probably be mentioned to you by enrollment specialists, health care providers, and advocates.
300 percent of the Federal Poverty Line (FPL) for an individual is approximately $32,676 (NOTE every April 1- the FPL amount will increase/be adjusted) and to find what 300 percent FPL for a family is, add an additional $11,460 for each additional dependent to amount for an individual (see the Insurance Partnership's web site for a better understanding of the FPL which is also referred to as income ceilings). However, annual gross income for those who are self-employed, seasonal workers, don't have regular pay stubs, and/or have combination income sources (W-2 income, 1099 income, etc.), is determined differently from those with just W-2 income wages with regular pay stubs. Those whose income is not solely from W-2 income sources with regular pay stubs, should contact an enrollment specialist in person to determine what their income is.
• MassHealth is the State's Medicaid program and the State Children Health Insurance Plan (SCHIP). It is important to know that it exists. In order to be enrolled into Commonwealth Care, an individual or family must first be screened to see if they are eligible for any MassHealth program. Please note children whose parents are enrolled in Commonwealth Care will not be covered by Commonwealth Care. The dependent children will be covered by SCHIP. Also some children may be eligible for SCHIP even if their parents are not eligible for any of the subsidized health care programs. You will be asked to fill out what is called a Medical Benefit Request (MBR).
From the MassHealth official web site:
MassHealth pays for health care for certain low- and medium-income people living in Massachusetts, including a program for individuals who are HIV positive. MassHealth also manages the Insurance Partnership for small businesses, the Children's Medical Security Plan, Healthy Start, and the Special Kids/Special Care Pilot Program, cosponsored with the Department of Social Services.
They have a great web site if you are interested in learning more in preparation for talking to an enrollment specialist/health care provider.
Of note they also have a Breast and Cervical Cancer Treatment Program.
• Insurance Partnership Program (IP) is a program of MassHealth and the AF has been working very closely with this organization since late 2005. This program can help eligible small businesses (those with 50 or fewer full-time employees) with uninsured employees (full time and part-time!) pay for health insurance. This program also helps the self-employed. The IP is not a health plan. It works in conjunction with qualified health insurance plans to make health insurance more affordable. There are income requirements for employees and the self-employed. Note the income guidelines for the self-employed is 300 percent of the Federal Poverty Line AFTER business expenses (i.e. not your gross income). That is line 22 on your 1040 federal income taxes.
Also if you identify as self-employed, meet the income requirements, and are currently insured (i.e. you are paying for your insurance yourself) you are more than likely eligible for IP assistance (before you had to be uninsured for six months to be eligible as a self-employed person). You will be asked to fill out what is called a Medical Benefit Request (MBR).
Remember, if you apply to the Insurance Partnership as a self-employed person you can not switch into the Commonwealth Care Program. The same holds true if someone is currently enrolled/participating as a self-employed person in the IP program. Contact the AF if you are in "locked into" the IP program as we are keeping track of this email@example.com
Contact info: 1-800-399-8285.
Please make sure to read, what to expect and how to prepare for interacting with an enrollment specialists/health care provider, before you make your call to Betty or any enrollment specialist.
• School/University Based Insurance Programs/ and or you have insurance through your parents' insurance plan
These student plans tend to have high deductibles/co-payments and other out of pocket costs. They also usually have an annual limit on benefits or benefit caps on the amount they will pay out per year for coverage (i.e. they may only cover a total of $50,000 worth of medical bills per year and after you hit that amount you are responsible for the bills). There has been a change, however, that may benefit those 26 and under. Many young adults may be able to stay on your parents' health plan, which in most cases is much better than what is offered by your school.
The Dependent Coverage Extension Requirement, which is part of the Health Care Reform Law, went into effect on Jan 1, 2007. Health plans are now required "to offer dependent coverage to young adults for two years after they lose their dependent status under federal tax law or to age 26, whichever comes first. The two-year time period will begin running on December 31st of the final year that a young adult's parents can claim him or her as a dependent on their federal tax returns. Parents can claim a child as a dependent on their federal tax returns in years that they provide at least one-half of the child's financial support." Quoted from: A Healthy Blog on HCFA's web site.
Please note that the Dependent Coverage Extension Requirement does NOT apply to self-insured/self-funded plans. To find out if your plan is a self-insured/self funded plan, call your HR person or your health plan directly (FYI usually large employers, federal, state and city health plans have self-insured/self funded plans).
The Commonwealth Choice Plans and the Young Adult Plans offered through the Connector may also be better options than the plans offered by your school.
• COBRA is the Consolidated Omnibus Budget Reconciliation Act (COBRA) that was passed in 1986 which according to US Labor Department's web site: "provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. This coverage, however, is only available when coverage is lost due to certain specific events. Group health coverage for COBRA participants is usually more expensive than health coverage for active employees, since usually the employer pays a part of the premium for active employees while COBRA participants generally pay the entire premium themselves. It is ordinarily less expensive, though, than individual health coverage."
• Massachusetts Division of Unemployment Assistance Medical Security Program, as stated on the web, "The Division of Unemployment Assistance provides health insurance assistance through the Medical Securities Program (MPS) for Massachusetts residents while they are receiving unemployment benefits. Massachusetts is the first state in the nation to offer a health care plan for unemployment insurance claimants. If you are eligible for unemployment insurance benefits in Massachusetts, you and your family may also qualify for health insurance coverage under the Medical Security Program. The program provides eligible claimants with either partial reimbursement of existing health insurance premiums or enrollment in a Blue Cross Health Maintenance Organization. These health insurance benefits are available to unemployed Massachusetts residents who meet program eligibility criteria."
• Commonwealth Care is a new State program for the uninsured established by the Health Care Reform Law. From the Connector's web site: "Commonwealth Care is a health insurance program that is administered through the Connector. Coverage under Commonwealth Care will be through a choice of private health insurance plans. The Connector will help eligible individuals choose and enroll in a health plan that works for them. A health plan includes a group of providers, hospitals, and other professionals who work together. Once enrolled, individuals will become a member of the health plan they select. Commonwealth Care members must pay a small fee (co-payment) for some Commonwealth Care benefits. In addition Commonwealth Care members with incomes greater than 100% of the Federal Poverty Level (FPL) must pay a monthly premium in order to enroll in a health plan. The premium these members pay will depend on their household income level."
These plans are subsidized on a sliding scale dependent on one's income level. The way this program quantifies income eligibility is by projected yearly gross income or monthly gross income (i.e. pretax money). So if you are not sure what your actual monthly gross income is or what your annual gross income is going to be- they may ask to see your last one or two year's Federal tax returns or may ask you over the phone what your gross income was for the past year or so.
There are four health insurance plans that are available through Commonwealth Care: Boston Health Net, Fallon Community Health Care, Network Health, and Neighborhood Health Plan. Not all of the health plans are available in every city or town. Only Boston Health Net is available state-wide.
Each of the Commonwealth Care Health Insurance plans offer four types/levels and those types/levels are based on an individual's income level. Each type/level has a different premium level, benefits and/or co-pays. Plan Type 1 is available to those 100 percent below the FPL. Plan Type 2 is for those between 100-200 percent of the FPL, and Plan Types 3 or 4 are available to those between 200- 300 percent of the FPL.
To apply for Commonwealth Care program you will be asked to fill out what is called a Medical Benefit Request (MBR). Those forms are available on line and at community health centers, health advocacy organizations, and hospitals. It is best, however, to work with an enrollment specialist if you are self-employed or have combination income. You can also be enrolled in a MBR via Health Care for All's Helpline.
It is important to understand that the state first has to make sure you are not eligible for any MassHealth Programs. So you will get a rejection letter from MassHealth before you find out if you are eligible for Commonwealth Care. There are no family plans for Commonwealth Care. Each adult in the household will pay an individual premium based on overall the family/household size and household income level. Household dependent children will be covered by a MassHealth program (SCHIP). Also some children may be eligible for SCHIP even if their parents are not eligible for any of the subsidized health care programs. As long as a parent is enrolled in Commonwealth Care, the state is waiving the premiums/fees usually paid for a dependent child or children on a MassHealth Program.
PLEASE note the following: There are eligibility requirements that the Connector's web site DOES NOT list (the AF, the ACT coalition, and HCFA have notified them of this oversight and they are working to address it)
Here are some of the eligibility requirements that we are aware of. Again there may be legal loop holes an enrollment specialist can use to enroll you into this program that we are not aware of. The advocates are keeping track of those not eligible for Commonwealth Care to be able to make the case to change this program to be more inclusive- so it is important to still call them even if you think you are not eligible for this program. REMEMBER if you enroll into Commonwealth Care health plan- you have 60 days to change your health plan if you are not satisfied.
The eligibility requirements we are currently aware of:
-Your gross income must be at or below 300 percent of the Federal Poverty Level. Please be aware that the FPL amount changes on April 1st - they go up! 300 percent of the FPL for an individual is approximately $32,676 and to find what 300 percent FPL for a family is, add an additional $11,460 for each additional dependent to $32,508 (see the Insurance Partnership's web site for a better understanding of the FPL which is also referred to as income ceilings).
- Annual gross income for those who are self-employed, seasonal workers, don't have regular pay stubs, and/or have combination income sources (W-2 income, 1099 income, etc.), is determined differently from those with just W-2 income wages with regular pay stubs. Those whose income is not solely from W-2 income sources with regular pay stubs, should contact an enrollment specialist in person to determine what their income is.(Contact Health Care for All's Help line or an enrollment specialist at a community health center, hospital, or at a health care advocacy organization).
-You are a US citizen, National or a legal alien
-You are age 19 or older (NOTE for those 18 years old: Even though you are not eligible for Commonwealth Care because of your age, you may be eligible for a Mass Health Program. So it is still worth your while to contact an enrollment specialist at the Health Care for All's Help Line or your local community health center or hospital. Also see our section for Students on this site.)
You must be uninsured- by the definition the Connector has set forth- BUT THEY have yet to list that that information the Connector web site or Commonwealth Care's web site.
You are considered uninsured if:
-You are currently insured under COBRA or the Small Group Health Insurance Continuous Coverage Act
-You are paying the full premium (ie you are paying 100 percent of the full premium cost) for you health insurance in the private insurance commercial market. NOTE-even if you are a member of an association/union/chamber of commerce- and are getting "a group rate" for your health insurance- as long as you are paying 100 percent of the premium you are considered uninsured.
-You are in a waiting period prior to becoming eligible under an employer-provided health plan for which the employer covers at least 20% of the annual cost of the premium of a family health pan or 33% of an individual plan.
You are considered INELIGIBLE even if you are uninsured- if you meet one of the following:
-If you are eligible for Student Health Insurance Program, available to full-time or part-time students in a Massachusetts public or independent institution (i.e. community college, college, or university). There has been a key change for students/young adults dependents under the new health care reform law that is noted in an earlier section.
-If you are eligible for the Insurance Partnership, either through your employer(s) or as a self-employed person. (NOTE only if you identify yourself as self-employed will you be eligible for the IP- this will be further explained in the section what to expect and how to prepare for interacting with an enrollment specialists/health care provider)
-If you are eligible for any of the following other programs: Medicare, Tricare, Massachusetts Fisherman's Partnership Inc. (only if 50% of your income is from fishing), Massachusetts Division of Unemployment Assistance Medical Security Program, MassHealth and/or Children's Medical Security Plan (aliens with special status eligible for MassHealth limited may receive Commonwealth Care)
***If in the last six months a family member's/spouse's current employer covered at least 20% of the annual cost of the premium of a family health plan or 33% of an individual plan and you are eligible to be on the plan; if your spouse or family member was enrolled in and is currently enrolled in college/university and they are eligible for the student health insurance and you could go on that plan as a dependent; or if your own current employer offered or is offering you health insurance that covered at least 20% of the annual cost of the premium of a family health plan or 33% of an individual plan.
***In other words if your current employer or your family's/spouse's current employer/school was meeting the above requirements and you still couldn't afford the health plan they offered and you chose not go on the plan YOU are not Eligible for Commonwealth Care.
You will have to go with out insurance for six months to become eligible for Commonwealth Care. This is commonly referred to as the six month look back.
Note if you are unemployed/lost the job that offered you insurance (or your family member/spouse did) you or they may be eligible for the Division of Unemployment Assistance's health insurance assistance program called the Medical Securities Program (MPS) that is for Massachusetts residents while they are receiving unemployment benefits. If you are not eligible for that program, you may be eligible for Commonwealth Care.
What happens if I enrolled and got accepted into Commonwealth Care and my employer or one of my employers offers me insurance AFTER I have enrolled in Commonwealth Care?
If your employer or one of your employers offers you insurance AFTER you have enrolled in Commonwealth Care and your employer offers to pay 33 percent or more of your individual plan or 20 percent or more of your family plan you will be de-enrolled (effectively kicked off) from Commonwealth Care. This is going to be the case even if you can not afford the premium from the health insurance plan offered to you by your employer. BUT the Connector is reconsidering this provision. The Connector is possibly considering that the employer could pay the State the same amount they would be paying an insurance company and the Connector would allow the employee to stay on the Commonwealth Care program. Again join this site's list serve to be kept up to date on this issue and others.
• For more in-depth information on Commonwealth Care (what it covers, the cost of it, etc.), please see Health Care for All's section on it.
• Commonwealth Choice and "Young Adult Plans" are two new options for the uninsured that were established by the Health Care Reform Law. These health plans are purchased through and are overseen by the Connector. These plans became available on May 1, 2007 and coverage may start as early as July 1, 2007. These plans are not subsided health insurance plans, but are lower priced market based health plans. You will not be asked to fill out what is called a Medical Benefit Request (MBR). These plans are available as individual plans and as family plans. DO NOT apply for these plans off the Connector's website or via their phone lines until you are sure you are not eligible for Commonwealth Care or a MassHealth Program. Only use them for research and make sure you talk to an enrollment specialist either from Health Care for All's Help line or a enrollment specialist from a community health center, hospital, or a health care advocacy organization, before you purchase these plans.
Commonwealth Choice plans are for adults 18 years of age and older. As individual, you can buy the Commonwealth Choice Plans directly through the Connector OR you can purchase them directly from the insurance carrier/company, through an insurance broker, via the Insurance Partnership, and/or through a membership based association/organization.
From the Connector web site:
"... the Connector will also offer a broad choice of approved health plans primarily to individuals and small employers (with less than 50 employees). This choice of private coverage called Commonwealth Choice. Commonwealth Choice will offer an array of health plans to small-group and non-group buyers at three different levels of benefits & premiums, representing the most popular choices. In addition, individuals aged 19 to 26, who do not qualify for group health benefits, may purchase lower cost "Young Adult Plans" exclusively through the Connector."
The Young Adult plans (YAPs) are only available as individual plans and can ONLY be purchased through the Connector (i.e. you can not buy a family plan). Also a buyer beware on the Young Adult plans. Like the student health insurance plans all of the YAP plans, with the exception of the Blue Cross Blue Shield Young Adult Plan, have an annual limit on benefits or benefit caps on the amount they will pay out per year for coverage (i.e. they may only cover a total of $50,000 worth of medical bills per year and after you hit that amount you are responsible for the bills). Make sure you know what you are buying and what the YAP covers and what its benefit cap is before you buy it. There has been a key change for eligibility- now people between 18-26 years of age are eligible for these plans (it was 19-26).
IMPORTANT KEY INFORMATION: IN 2010 the insurance companies convinced the state legislature that people in the private insurance makret were "gaming the system" and causing the insurance companies to lose money. So the state legislature changed the law governinng when and under what circumstances individuals can buy insurance in the private market place. No advocates were consulted on this change before it became law. This new law did not change the rules for those in subsidized care, or how businesses can buy insurance. The law only changed it for those individuals who earn over 300 percent of the Federal Poverty Line. (For the record the Artists Health Care Working and Healthcare for Artists.org were against how this change was put into place and testified against it).
There is now a strict open enrollment period and if individuals miss that period they will more than likely be locked out of buying insurance unless they have a "qualifying event". Note if your employer offers you insurance and it meets minimal credible coverage, you are not allowed to forgo you employer's insurance and buy insurance on the private market place- unless you have a qualifying event (so if you dont' like the insurance your employer is offering you is not sufficent to allow you to buy private insurance even if you can afford it). Note the same applies on the YAP plans as it does in the private insurance market. For more information see the Connector's PDF fact page. We also urge you to call Health Care for All's FREE Helpline for information and help: 1-800-272-4232. AND call your state representative and state senator and urge them to change this law!
KEY Commonwealth Choice and Young Adult Plans information:
There are six insurance companies that are participating in "different areas of the state." Not all of the plans are available in each city or town. They are: Neighborhood Health Plan, Fallon Community Health Care, Tufts Health Plan, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, and Health New England. The AF is awaiting clarification if Commonwealth Choice Plans and the Young Adult Plans can be purchased through the Insurance Partnership Program. Remember not to enroll into any plan you can not afford- AGAIN we recommend you first try to see if you are eligible for Commonwealth Care before you enroll in Commonwealth Choice.
SPECIAL NOTE for those researching Commonwealth Choice Plans- you can sign up on line for these plans on-line BUT you may want to speak to someone BEFORE you sign up for them to make sure you understand what exactly the plans cover and what they don't cover- the fine print matters! You can call the Connector to "research" what the plans cover or the health plan carrier directly.. For these plans you do not have to disclose/show what your income is or fill out a MBR form.
All of the six insurance companies offer the following levels/types of plans:
Bronze- these are the lowest level of the plans and they have the highest deductible and the lowest monthly premiums. Also both the CO-pays and co-insurance amounts are the highest of all the plans. For only this year, you can purchase Bronze plans with or without prescription drug coverage.
Silver- these plans have higher monthly premiums than the Bronze plans. From what we can tell most Silver plans do not have a deductible (you need to check carefully) and the CO-payments are less than Bronze plans. These plans also have have a bigger provider network than Bronze Plans (more doctors to choose from). All silver plans have prescription drug coverage.
Gold- These plans have no deductibles, but they have higher monthly premiums than both the Silver and Bronze plans. The Gold plans also have the lowest CO-payments The provider networks (i.e. choice of doctors) for Gold plans are bigger than both the Silver and Bronze plans. Gold plans also have prescription drug coverage.
Young Adult Plans- For 18-26 year-olds. From the Connector website: "Low premium. Most have deductibles, CO-payments, and an annual limit on benefits. Available with and without prescription drug coverage."
We have heard that, if your employer is paying at least 33 percent of your individual plan or 20 percent of your family plan, you can not opt out of their employer sponsored insurance (ESI) to buy a Commonwealth Choice Plan or a Young Adult Plan EVEN if those plans are cheaper or better than your ESI offered plan. We are trying to find out if this is indeed true.
It has been confirmed that the self employed and those employees enrolled in the Insurance Partnership can purchase Commonwealth Choice Plans via that program. We are waiting for more information on how this can be done. We are also still waiting on if you can do so with Young Adult Plans through the Insurance Partnership program.
To learn more about these plans you can call the Connector toll free at 1-877-623-6765 (1-877-MA-Enroll) or visit their website for more information.
We strongly recommend that artists who have hard to determine income DO NOT enroll or sign up for any program/health insurance plan via the Connector's website or phone lines. Only use the Connector as a way to research your options. This is very important. It is best if you talk to a seasoned enrollment specialist from Health Care For All's Help Line or an enrollment councilor from a Community Health Center, a hospital, or a health care advocacy organization to see if you are first eligible for a subsidized health plan and if you find out that you are not eligible THEN use the Connector to enroll in a non subsidized health plan (i.e. Commonwealth Choice plans).It is important to be able to have an enrollment specialist to be able to advocate on your behalf or with you if something does not go smoothly with your enrollment.
• Other health care options listed on Health Care for All's web site (make sure you look at both the Public Programs section and the Private Program section) and we also recommend Community Partner's Program Info & Tools section: http://www.compartners.org/tags/tools-and-resources