Commonwealth Choice

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 Commonwealth Choice helps people find health coverage.  Commonwealth Choice is the state program that works with health insurers to develop qualified policies that have the Connector’s Seal of Approval.  If you are covered by a Commonwealth Choice policy, you have satisfied the requirement to have qualified minimum creditable coverage.  Commonwealth Choice also helps individuals and employers find and compare these policies. 

When Can I Get Individual Health Insurance Through Commonwealth Choice?

  • In Massachusetts, your ability to buy individual health insurance from Commonwealth Choice does not depend on your health status. Commonwealth Choice plans are not permitted to turn you down because of your health status and other factors.

What Will My Individual Health Insurance Purchased Through Commonwealth Choice Cover?

  • Commonwealth Choice plans offer four levels of coverage. They are labeled Gold, Silver, Bronze, and Young Adult.

All plans provide coverage for inpatient care, outpatient care, physician, mental health services, x-ray and lab, physical therapy, and durable medical equipment. Most plans cover prescription drugs, although insurers that offer Commonwealth Choice policies may also offer plan options that do not cover prescription drugs.  

Plan options have varying cost sharing requirements.  For example, some plans have no annual deductible while others have annual deductibles of $2,000 per person.  In addition, some plans impose a separate hospital deductible as high as $1,000 per admission.  In addition to the deductible, co-pays (for example, of $25) may apply for each covered service or prescription, co-insurance (for example, of 20%) may apply.

The Young Adult Plans may impose annual caps on covered benefits, ranging from $50,000 to $100,000 per year.

  • Individuals are required to purchase and maintain creditable coverage to meet the requirements under the individual mandate. Until 2009, all health benefit plans will meet this requirement. However, in 2009, qualifying creditable coverage will have to meet certain benefit standards. Starting January 1, 2009, to qualify as minimum creditable coverage, an insurance policy must at least provide coverage for preventative and primary care, emergency services, hospitalization, prescription drugs and mental health benefits. The annual deductible cannot be higher than $2,000 for an individual or $4,000 for a family.

NOTE: Currently there is no requirement for insurers to sell policies that meet the standards for minimum creditable coverage.  Starting in 2009, individuals must ensure that the policy purchased meet these standards to avoid a penalty.  However, all policies sold through Commonwealth Choice are required to meet these standards. 

What about coverage for my pre-existing condition?

  • If you buy individual health insurance through Commonwealth Choice you may face a pre-existing exclusion period. No pre-existing condition exclusion period can be applied unless you have a break of 63 or more days of continuous coverage. Pre-existing condition exclusion periods can last up to 6 months. Commonwealth Choice plans can look back 6 months to see if you actually received care or treatment for a condition. In addition, pregnancy can be considered a pre-existing condition in individual health insurance. Genetic information cannot be considered a pre-existing condition.
  • No preexisting condition exclusion period can be imposed if you are HIPAA eligible.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy individual health insurance and are exempted from pre-existing condition exclusion periods.  In Massachusetts, where state law is more protective, you do not need to meet all of the requirements of HIPAA eligibility to have this protection.  However, if you move out of Massachusetts, this information may be important to you. 

To be HIPAA eligible, you must meet all of the following:

  • You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
  • You also must have used up any COBRA or state continuation coverage for which you were eligible.
  • You must not be eligible for Medicare, Medicaid or a group health plan.
  • You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)
  • You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.

HIPAA eligibility ends when you enroll in individual health insurance, because the last day of your continuous health coverage must have been in a group plan.  You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

  • In Massachusetts, if you buy individual health insurance you may be subject to a waiting period for up to 6 months. Individual health insurers can impose either a pre-existing condition exclusion period or a waiting period but not both. If you are subject to a waiting period you will pay premiums but not receive coverage for non- emergency services during that time. No waiting period can be applied unless you have a break of 63 or more days of continuous coverage. No waiting period can be imposed if you are HIPAA eligible.

What can I be charged for individual health insurance purchased through commonwealth choice?

  • Premiums for Commonwealth Choice Plans cannot vary due to gender, health status, or occupation. However, premiums will vary based on age, family size, and where you live in the state. This is called modified community rating. Commonwealth Choice Plans and their premium rates can be viewed on the web at http://www.mahealthconnector.org/ or call the Commonwealth Connector at (877) MA-ENROLL (623-6765) for more information.
  • If you work for a Massachusetts employer, you must be offered a Section 125 plan. This will allow you to pay your health insurance premiums with pre-tax dollars and so reduce what you owe in federal and state income taxes.
  • If you cannot afford health insurance, you may be eligible for subsidized or free coverage through another program called Commonwealth Care. See Chapter 5 for more information.

Can my Commonwealth Choice policy be cancelled? 

  • Your coverage cannot be canceled because you get sick. This is called guaranteed renewability. You have this protection provided that you pay the premiums, do not defraud the company, and, in the case of managed care plans, continue to live in the plan service area.


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