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Rates increased by an average of 7.6% for 2023; Open enrollment runs through January 23
Massachusetts uses a state-based health insurance exchange (Massachusetts Health Connector), with eight carriers offering plans through the exchange. Average rates for plans sold in the Massachusetts exchange were the lowest in the country in 2020, as had been the case for the last few years, although they increased by about 8% for 2021, by about 7% for 2022, and by nearly 8% for 2023.
The individual mandate penalty in Massachusetts remains in effect. The state also has an easy enrollment program and extends the open enrollment window through January 23 each year. Massachusetts also caps age-based premiums at a 2:1 ratio (instead of the 3:1 ratio that’s allowed under the ACA), and goes beyond the ACA’s minimum requirements for medical loss ratios. Massachusetts is also one of only two states (the other is Maine) where the individual and small group markets are merged.
Massachusetts runs its own exchange (marketplace), Massachusetts Health Connector. Board meeting agendas and minutes for Massachusetts Health Connector are available here.
The Health Connector is an active purchaser exchange, which means the exchange determines which plans are offered for sale. The exchange prefers to limit the number of available plans as described below. There are eight insurers offering plans for 2023 (there were nine in 2022, but members of one of the Tufts affiliates’ plans are being transitioned to Harvard Pilgrim plans as of 2023 under a merger agreement, so only one Tufts affiliate is offering plans for 2023), which makes Massachusetts Health Connector one of the most robust exchanges in the country in terms of insurer competition. This 2018 Health Affairs article details some of the reasons for the exchange’s success.
The exchange in Massachusetts predates the ACA by several years; health care reform that took effect in Massachusetts in 2006 was widely considered a blueprint for the ACA. Massachusetts has a very robust exchange, with more participating carriers than most states.
Residents in Massachusetts have access to the federal ACA subsidies, and many (those with income up to 300% of the poverty level) also have access to state subsidies via ConnectorCare (details below).
Massachusetts and Vermont had long been the only two states where the individual and small group risk pools were merged, although Maine has merged its individual and small group markets as of 2023, and Vermont has separated its markets as of 2022 (DC also has a modified merged risk pool, but it operates more like the rest of the country, and less like Massachusetts), which means that the individual market is less volatile than many other states.
Outside of open enrollment, a qualifying life event is generally necessary to enroll in a plan or make coverage changes. But residents who are eligible for ConnectorCare can enroll anytime if they are newly eligible or haven’t previously enrolled. And subsidy-eligible applicants with income up to 150% of the poverty level can enroll anytime. Native Americans can also enroll anytime.
There are eight insurers that offer exchange plans in Massachusetts, with plan availability varying from one location to another:
The service areas of most of the insurers include much of the state, although insurer participation varies depending on the county. There are also some insurers in Massachusetts that only offer plans outside the marketplace.
Massachusetts Health Connector is one of the nation’s most robust exchanges, with eight insurers offering plans in 2019. But there have been some changes in insurer participation over the years:
UnitedHealthcare exited the individual market in Massachusetts at the end of 2016, but they covered just one percent of the exchange’s enrollees in 2016. Dental carriers Guardian and MetLife exited the exchange at the end of 2016, but they only offered group dental coverage, rather than individual market coverage.
Minuteman Health—an ACA-created CO-OP that operated in Massachusetts and New Hampshire—closed at the end of 2017. Facing financial instability, which Minuteman Health noted was due in part to the way the ACA’s risk adjustment program allocated money and the shortfall in risk corridor payments, the CO-OP announced in June 2017 that they would stop offering plans at the end of 2017, but their intention at that point was to reopen as a for-profit insurer in 2018.
In August 2017, however, it became apparent that Minuteman would not be able to reopen as a for-profit insurer in 2018, because they had not raised enough capital by the August 16 deadline to get licensed as a new insurer. As a result, Minuteman Health enrollees in Massachusetts and New Hampshire had to switch to new plans for 2018, and did not have an opportunity to buy a for-profit version of Minuteman coverage.
A July 2017 Health Connector memo indicated that CeltiCare (Ambetter) would not participate in the individual market in Massachusetts in 2018. But Massachusetts Health Connector’s July enrollment report noted that CeltiCare had zero percent of the QHP and small group enrollments in 2017, and just 1 percent of the ConnectorCare enrollments. So their departure did not have a significant impact.
For 2019, UnitedHealthcare returned to the exchange, although not of their own volition. Their return was triggered by the state’s rule that requires insurers that cover at least 5,000 people in the merged individual/small group market, and UnitedHealthcare hit that threshold in 2018.
For 2023, Massachusetts Health Connector’s insurers implemented the following average rate changes, which amounted to an average increase of 7.6%:
Because Massachusetts has a merged individual and small group market, each carrier’s rate changes apply to both individual and small group plans. When the weighted average rate change is calculated using enrollment in group and non-group coverage, the average rate increase for 2023 is 6.6%.
As is always the case, approved rate changes reflect how premiums for full-price plans would change for the coming year. For individual market enrollees who have premium subsidies through the Massachusetts Health Connector, after-subsidy rate changes can differ significantly from the average rate change that applies to a given insurer’s plans.
And premiums increase due to a person’s increasing age each year, even if their health plan isn’t changing its overall rates at all. When age-related rate increases are taken into consideration, the average full-price premium increase for existing individual market enrollees amounts to 9.3% for 2023. But again, premium subsidies cover a large chunk of the premium costs for many enrollees, and subsidies do increase to keep pace with age-related rate increases.
Here’s a look at how premiums have changed for Massachusetts Health Connector plans over the years:
2015: Average increase of 1.6 percent for 2015.
2016: Average increase of 6.3 percent. This was well under the 12 to 13 percent nationwide average for 2016 (the nationwide average applies to the individual market along; Massachusetts and Vermont are the only two states where the individual and small group risk pools have been merged. DC also has a modified merged risk pool).
2017: Average increase of 19 percent. For people with income above 300 percent of the poverty level (who don’t qualify for ConnectorCare subsidies), average premiums increased by 19 percent, which was lower than the national average. That assumed, however, that people kept their existing plans in 2017. In reality, there was a much higher rate of plan switching during the 2017 open enrollment period: 65,000 Massachusetts Health Connector enrollees picked new plans for 2017, which was roughly four times the percentage of plan changes that the exchange had seen in prior years.
But ConnectorCare subsidies were also smaller in 2017, and people who are enrolled in the highest-cost plans were no longer receiving the level of ConnectorCare subsidies they received in the past. In a September Health Connector board meeting, this issue was explained in more detail: essentially, the larger spread of premiums for 2017 meant that the cost of “smoothing” premiums would have been excessive, and would “reward behavior in the market that is not competitive.”
In 2016, the cost of premium smoothing was $20 million. But with the large rate increases for some carriers in 2017, the cost of smoothing was going to run to $51 million if it was done without any changes from 2016. Adding to the problem is the fact that available funding for 2017 was much lower than it was in 2016, and only $4.2 million is available.
The result of all this was that the additional subsidies for ConnectorCare plans was concentrated on lower-cost plans for 2017. ConnectorCare premiums are being “smoothed” (ie, eliminated) for plans that are within $35/month of the lowest-cost plan, but not beyond that.
So while people on the lower end of the income scale were able to pick any ConnectorCare plan in 2016 without paying a premium, they had to pay a premium in 2017 if they selected one of the more expensive plans (premiums for people in ConnectorCare Plan Type 1—for the lowest-income enrollees—varied from $0 to $165/month in 2017, depending on the plan they select).
2018: Average rate increase of 18 percent, driven largely by an increase in silver plan rates after the Trump administration cut off federal funding for cost-sharing reductions. As of October 12, 2017 Massachusetts Health Connector intended to implement premiums for 2018 that were based on the assumption that cost-sharing reduction (CSR) funding would continue in 2018. The average rate increase at that point was just 8.7 percent.
But it was later that same day that the Trump Administration announced that CSR funding would end immediately. Suddenly, insurers in states that had taken Massachusetts’ approach (assuming CSR funding would continue) were left scrambling to sort out their path forward. In nearly every state, the eventual result was that the cost of CSR got added to 2018 premiums (typically just to silver plan premiums, as CSR benefits only apply to silver plans).
Massachusetts did ultimately allow insurers to add the cost of CSR to silver plan premiums for 2018 (this was only applicable to five of the exchange’s eight insurers, since the other three do not offer ConnectorCare plans, and CSR benefits are only available on ConnectorCare plans, since the income cap for ConnectorCare is higher than the income cap for CSR benefits). The result was that silver plan premiums increased by an average of 26 percent in Massachusetts, instead of the 10.5 percent average increase they would have otherwise had. Overall, the average rate increase across all plans was 18 percent, driven in large part by the spike in silver plan rates.
2019: Average increase of 4.7 percent. Average premiums for Massachusetts Health Connector plans are 4.7 percent higher for 2019 than they were for 2018. The average increase by insurer ranged from a 1.4 percent average increase for Tufts Health Plan Direct (which covered 43 percent of the state’s exchange enrollees) to 11.3 percent for Fallon Health (which covered just 4 percent of enrollees):
The exchange reported that for the 58,021 members who weren’t receiving any subsidies, average premiums (assuming they kept their existing plans) would be 2.7 percent higher in 2019.
State law in Massachusetts requires insurers to sell plans on the exchange if they have more than 5,000 enrollees in the merged individual/small group market. As of 2018, UnitedHealthcare had more than 5,000 enrollees in small group plans in Massachusetts, so they had to file plans to offer on-exchange coverage in both the individual and small group markets for 2019 (but only in the Boston metro area). But David Wichmann, chief executive of UnitedHealth Group, clarified that returning to the exchange “wasn’t necessarily a voluntary decision on our part.”
UnitedHealthcare previously participated in the Massachusetts exchange, but exited at the end of 2016. They have voluntarily returned to several other states’ exchanges in 2022 and 2023.
2020: Average increase of 5.2 percent. The weighted average rate increase for 2020 was about 5.2 percent. It ranged from a slight decrease for Harvard Pilgrim to a 7 percent increase for BMC HealthNet.
2021: Average increase of 7.9%. As of September 2020, rates had been approved by the Massachusetts Division of Insurance. The approved rates amounted to an overall average increase of 7.9%, which was a reduction of about 1 percentage point from what the insurers had originally filed. Massachusetts Division of Insurance deputy commissioner, Kevin Beagan, expressed grave concerns about the rate increases, but noted that the uncertainties around COVID costs resulted in higher premiums than the Division would otherwise have approved.
2022: Average increase of about 7%. For 2022, Massachusetts Health Connector’s insurers implemented rate changes that amounted to an average increase of 6.9%.
Massachusetts caps the age rating ratio for premiums at 2:1, so older enrollees cannot be charged more than two times as much as younger enrollees. The ACA set the ratio at 3:1, which nearly every other state utilizes. New York and Vermont are the only other states that don’t use the 3:1 ratio, and they both prohibit age rating altogether, using a 1:1 ratio instead.
Massachusetts also imposes an 88% medical loss ratio requirement for individual and small group plans. Under the ACA, federal law requires health plans in the individual and small group market to send rebates to consumers if their medical loss ratios are under 80%. But in Massachusetts, rebates are required if a carrier’s medical loss ratio is under 88%.
ConnectorCare plans are qualified health plans (QHPs), but they have year-round enrollment (albeit with limitations). ConnectorCare plans qualify for the federally-funded ACA premium tax credits, but they’re also subsidized by the state, resulting in even lower premium and out-of-pocket costs for eligible residents. ConnectorCare plans are available to enrollees with incomes up to 300 percent of the poverty level, and there are three different plan levels depending on enrollees’ income level.
ConnectorCare plans are offered by five of Massachusetts Health Connector’s insurers, with some coverage area changes for 2023:
Although MassHealth (Medicaid) enrollment is available year-round to any applicant who’s eligible for coverage, ConnectorCare is only available outside of open enrollment if the enrollee is either newly eligible (ie, didn’t qualify for ConnectorCare in the past) or hasn’t previously applied.
Starting in 2017, people who have ConnectorCare health insurance plans through Massachusetts Health Connector no longer have to pay copays if they need outpatient substance abuse treatment or medications, including Methadone and Suboxone.
The new rules do not apply to people who pay full-price for their coverage, or for those with income between 300 and 400% of the poverty level, who qualify only for the ACA’s subsidies, but not ConnectorCare. But more than three-quarters of the Massachusetts Health Connector’s private plan (QHP) enrollees are in ConnectorCare plans.
ConnectorCare is essentially the ACA-compliant replacement for Massachusetts’ pre-ACA Commonwealth Care program. Commonwealth Care also provided state-subsidized coverage for residents with incomes up to 300% of the poverty level, but it was scheduled to terminate at the end of 2013 and be replaced with ConnectorCare. Due to technological problems, the transition was delayed until 2015. Commonwealth Care was closed to new enrollees as of the end of 2013, but it continued to provide coverage for existing members until January 31, 2015. Commonwealth Care members needed to transition to ConnectorCare or another program (depending on eligibility) as of February 2015. The Commonwealth Care program’s regulations were officially repealed by the Massachusetts Health Connector’s board during their June 2015 meeting.
Massachusetts has had an individual mandate since 2006, and it remains in effect after the ACA’s individual mandate penalty was eliminated at the end of 2018. The state re-implemented employer health coverage reporting in 2018, after suspended it in 2014, when the ACA took effect. The employer mandate and associated employer informational reporting will remain in effect at the federal level in 2019 and beyond, but the state has begun enforcing its own individual mandate again in 2019, so employer reporting once again plays a role.
Penalty amounts under Massachusetts’ individual mandate are based on residents’ income and the cost of various plans in the exchange. And unlike the ACA penalty, the Massachusetts penalty only applies to adults. From 2014 through 2018, the cost of federal individual mandate penalties were subtracted from the state’s individual mandate, so people didn’t have to pay both penalties if they were uninsured in Massachusetts. But starting in 2019, the state’s penalty will apply in full. 2018 penalty amounts for Massachusetts are available here.
In an effort to offset the financial impact of employers shifting the cost of health care onto the state, and to help cover the state’s increasing Medicaid expenses, Massachusetts enacted H.3822 in 2017. The legislation imposes a financial penalty on employers if they have employees who enroll in MassHealth (Medicaid) or ConnectorCare (state-subsidized health insurance available through the exchange). The penalty is called the Employer Medical Assistance Contribution Supplement, or EMAC Supplement, and has been implemented for 2018 and 2019.
The EMAC Supplement is collected as a line item on the employer’s quarterly unemployment contributions (starting with the April 2018 contribution), and is equal to 5 percent of the wages of the employee who enrolled in MassHealth or ConnectorCare, although there’s a cap on the penalty of $750 per year, per employee. The EMAC Supplement applies to employers with six or more employees — a far lower threshold than the ACA’s employer mandate, which only requires employers to offer health coverage if they have 50 or more employees.
To be clear, the new Massachusetts rule does not require small employers to offer coverage. But it charges them an assessment (smaller than the ACA’s employer-mandate penalty, but not insignificant) if their employees have income that makes them eligible for MassHealth or ConnectorCare. To avoid the EMAC Supplement charge, the employer can either boost wages or offer affordable coverage.
If an employer offers affordable, minimum value coverage and the employee rejects it, the employee would not be eligible for ConnectorCare, since that coverage isn’t available to people who have access to an affordable employer-sponsored plan that provides minimum value. But a person whose income is low enough to qualify for MassHealth is eligible regardless of access to employer-sponsored coverage, so an employee whose wages are low enough to qualify for MassHealth would trigger the employer penalty under the new EMAC Supplement system.
The EMAC Supplement charge does not apply to employees who earn less than $500 in wages during the quarter, and it also does not apply to disabled workers. It also does not apply if an employee obtains coverage via the Massachusetts exchange and qualifies for only ACA-premium subsidies. Those subsidies are provided by the federal government. But ConnectorCare subsidies are provided by the state, and the EMAC Supplement is intended to defray some of the state’s costs.
Incidentally, a 2013 report that listed employers with more than 50 employees receiving state-subsidized coverage under safety-net health plans (mostly MassHealth) indicated that the Commonwealth of Massachusetts was the employer with the highest number of employees receiving state-subsidized coverage, followed by S&S Credit Company and then WalMart.
In addition to the EMAC Supplement that applies if employees are enrolled in MassHealth or ConnectorCare, H.3822 also temporarily increases the existing EMAC (which has been in place since 2014) from a maximum of $51 per employee per year to a maximum of $77 per employee per year. This fee applies to employers with six or more employees, regardless of whether employees are enrolled in state-funded health care programs, and regardless of whether the employer offers coverage. The temporary increase applies in 2018 and 2019. There is expected to still be a budget shortfall for MassHealth, even with the higher EMAC and EMAC Supplement revenue.
Massachusetts Health Connector offers both standardized and non-standardized plans from which enrollees can select. The standardized plans have the same out-of-pocket costs (within a metal level) for various benefit categories (eg. deductible, out-of-pocket maximum, office visit, emergency room, etc.), although standardized plans can vary significantly in terms of premiums, provider networks, and cost-sharing for benefits outside of the standardized categories.
Massachusetts carriers can—and do—also offer non-standardized plan designs that comply with the ACA’s requirements but have different out-of-pocket costs for the nine benefit categories that apply to standardized plans.
Massachusetts Health Connectors is an active purchaser which means that the exchange sets criteria for participating health plans, negotiates with insurers, and ultimately decides which health plans will be for sale through the exchange (some states have clearinghouse exchange models instead, which means the exchange accepts all plans that meet the QHP guidelines). As an example, the Connector requires each participating carrier to offer plans at all four metal levels; the ACA only requires exchange carriers to offer at least one gold plan and one silver plan (in many areas of the country, there are no longer any platinum plan for sale; in Massachusetts, there are platinum plans for sale from each of the insurers).
The exchange utilized its active purchaser role for 2016 to limit the number of available plans. For 2015, there were 126 plans are available, and the Connector said that would decrease to 81 or fewer for 2016. The exchange felt the previously-available plethora of plan options—often with only minor differences from one plan to another—made the selection process too confusing for enrollees. By 2018, there were only 52 individual market plans for sale via MA Health Connector, although that increased to 57 for 2019. For 2023, there are 45 non-ConnectorCare individual market plans available through Massachusetts Health Connector.
The move to simplify plan offerings starting in 2016 was met with mixed opinions from board members and stakeholders.
On February 23, 2017, DC Health Link, the state-run exchange in the District of Columbia, announced that they would be partnering with Massachusetts Health Connector, so that small businesses in Massachusetts would be able to use DC Health Link’s SHOP (small business exchange) enrollment platform.
The new website, which uses a separate branch of DC Health Link’s SHOP exchange platform, launched in August 2017, with plans available from Boston Medical Center Health Plan, Fallon Health, and Health New England. Additional insurers have since been added to the platform: As of 2019, Massachusetts Health Connector’s SHOP exchange offers small business plans from BCBSMA, Fallon Health, Harvard Pilgrim Health Care, Health New England, Tufts, and UnitedHealthcare. There are also small group dental plans available from Altus Dental and Delta Dental.
The Massachusetts Health Connector’s small business exchange offers plans to employers with up to 50 employees. The ACA had called for the definition of “small group” to expand to include groups with up to 100 employees starting in 2016, and Massachusetts had issued guidance allowing groups with 51 – 100 employees to early-renew their plans at the end of 2015 to avoid rate hikes in 2016 under the new regulations.
But in October 2015, President Obama signed HR1624 (the PACE Act) into law, repealing the ACA’s small group definition change, but leaving the final decision up to each state. Massachusetts is keeping their small group definition at 50 or fewer employees, and the day after HR1624 was enacted, the state rescinded their guidance that allowed mid-size groups to early renew.
In March 2018, Massachusetts Health Connector began a partnership with the New England Business Association, to make health coverage more accessible to small businesses.
Massachusetts enacted comprehensive health reform in 2006 that created the Massachusetts Health Connector. Massachusetts’ reforms served as the model for the federal Affordable Care Act (ACA), which was signed into law in 2010. As a result of Massachusetts’ early health care reform efforts, the state’s uninsured rate had dropped from 10.9% in 2006 to 6.3% in 2010—in contrast to the overall uninsured rate in the US, which climbed during that time period.
While the ACA health insurance marketplaces were modeled on the Massachusetts exchange, the technical upgrades that were needed to make Health Connector ACA-compliant were not implemented smoothly or on time.
The Health Connector performed very poorly during the first ACA open enrollment period. Health Connector hired a consultant, MITRE Corporation, to assess its website problems. MITRE determined that CGI—the lead IT vendor—lacked the necessary expertise, managed the project poorly, lost data, and failed to adequately test the revamped website prior to its launch. MITRE also said the roles and decision-making authority of the three state entities involved in the project (Massachusetts Health Connector, MassHealth, and the University of Massachusetts Medical School) were unclear.
Despite the issues with CGI, state officials deemed it too disruptive to cut ties with the vendor during the 2014 open enrollment. In January 2014, Massachusetts brought on Optum, a subsidiary of United HealthGroup, to work through some of the immediate problems with the Health Connector. When 2014 open enrollment ended, Health Connector officials moved to terminate the CGI contract.
The Health Connector struggled with technological problems during 2014 open enrollment, and officials spent the spring and summer evaluating whether to fix the state’s system or transition to HealthCare.gov.
Massachusetts officials pursued a “dual track” solution to make the Health Connector work better for the 2015 open enrollment period. One track evaluated replacing existing Health Connector software with hCentive, an off-the-shelf software solution that was successfully used by the Colorado, Kentucky, and New York exchanges. The second track considered was transitioning to the federal exchange, HealthCare.gov, for enrollment.
In July 2014, hCentive successfully demonstrated that it could connect to the federal data hub to verify applicants’ identities and income levels. After additional testing in August, Massachusetts and CMS determined that continuing as a state-run exchange using the hCentive platform was the right approach for the state.
The hCentive system was customized for the Massachusetts insurance marketplace. It supports State Wrap, which provides additional state-sponsored premium assistance (ConnectorCare), as well as a “single door” enrollment for either private health insurance or MassHealth, the state’s Medicaid program. The hCentive system also includes functionality to better handle transactions between insurance companies and consumers and “back office” functions for insurers.
State officials put the cost of rebuilding the Health Connector at $254 million, with the state paying $30 million and the federal government paying the balance (by October 2015, the total had reached $285 million). In addition, the state has paid $259 million in medical claims for people who were temporarily enrolled in MassHealth due to the exchange’s inability to accurately determine eligibility for financial assistance in 2014.
Health Connector performance was greatly improved in 2015. However, officials acknowledged many additional fixes were still needed. Gov. Charlie Baker was sworn into office in January 2015, and he moved quickly to bring changes to the Health Connector leadership ranks. Baker is a Republican, and was formerly the CEO of Harvard Pilgrim Healthcare. During Baker’s campaign for governor, he was critical of the Connector’s botched roll-out, and felt that Massachusetts should have more waivers from the ACA, given that the state had already implemented successful healthcare reform.
Massachusetts Health Connector’s technical problems had mostly been addressed by the start of the third open enrollment period, and the 2016 open enrollment period was dramatically more successful than the previous two. Renewal for enrollees who didn’t make changes to their plan was much faster than it was for 2015, and the exchange also added online accessibility for payment and change of circumstances requests—those features were previously only available by calling the help center. Call center hours were extended for open enrollment, and staffing was increased to more than 300 call center representatives.
The exchange also added four new walk-in centers (Brockton, Fall River, Lowell, and Springfield) to handle open enrollment volume, in addition to the existing walk-in locations in Worcester and Boston.
Massachusetts Health Connector also partnered with Consumers’ Checkbook to create a provider search tool that enrollees could use without leaving the Connector website. Prior to the 2016 open enrollment period, enrollees had to leave the Connector site and use the network search tools provided by each insurer—a cumbersome process at best—to make sure their doctors were in the network of the plans they were considering.
Massachusetts Health Connector
State Exchange Profile: Massachusetts
The Henry J. Kaiser Family Foundation overview of Massachusetts’ progress toward creating a state health insurance exchange.
Health Care for All – Massachusetts Consumer Assistance Program
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.(800) 272-4232
Office of Patient Protection, Department of Public Health
800-436-7757 (toll-free nationwide)
Serves residents and other consumers who receive health coverage from a Massachusetts carrier, insurer, or HMO.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
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