At a glance: Medicare health insurance in Massachusetts
- More than 1.3 million Massachusetts residents are enrolled in Medicare.
- About 24 percent of Massachusetts Medicare beneficiaries are enrolled in Medicare Advantage plans.
- The Medicare Advantage market is robust in most of Massachusetts, but there is just one Advantage plan available for purchase in Dukes County and Nantucket County.
- Ten insurers offer Medigap plans in Massachusetts. The state conducts its own Medigap standardization, so there are only two plan designs available (as opposed to ten in most states). Massachusetts also has strong consumer protections for Medigap coverage.
- There are 26 stand-alone Part D prescription plans available in Massachusetts in 2019, with premiums that range from about $14 to $128 per month.
- Per-enrollee Original Medicare spending in Massachusetts is a little lower than the national average.
Medicare enrollment in Massachusetts
As of December 2018, there were 1,313,191 Massachusetts residents enrolled in Medicare. For most Americans, Medicare eligibility starts when they turn 65. But Medicare also provides coverage for younger Americans after they have been receiving disability benefits for 24 months, or if they have ALS or end-stage renal disease.
Seventeen percent of Medicare beneficiaries in Massachusetts are eligible due to disability rather than age; nationwide, it’s 16 percent. On the high and low ends of the spectrum, 23 percent of Medicare beneficiaries in Alabama, Kentucky, and Mississippi are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.
Medicare Advantage in Massachusetts
Medicare beneficiaries can choose to get their coverage via Medicare Advantage plans, or directly from the federal government via Original Medicare. There are pros and cons to either option, and the right solution is different for each person. Medicare Advantage plans are offered by private insurers, so plan availability varies from one area to another. Most of Massachusetts has a very robust Medicare Advantage market, with numerous plans available. But residents in Dukes and Nantucket counties have just one Medicare Advantage plan available in 2019.
Twenty-one percent of Massachusetts Medicare beneficiaries were enrolled in Medicare Advantage plans as of 2017. By December 2018, more than 24 percent of Massachusetts Medicare beneficiaries had Medicare Advantage coverage, mirroring the nationwide increase in Advantage plan enrollment. But more than three-quarters of Medicare beneficiaries in Massachusetts had opted for Original Medicare as of late 2018.
The popularity of Medicare Advantage varies from one state to another. In Minnesota, 56 percent of the state’s Medicare population is enrolled in Advantage plans, whereas only 1 percent of Alaska Medicare beneficiaries have Advantage plans (and those are via employer-sponsored coverage, as there are no Medicare Advantage plans available for individuals to purchase in Alaska).
Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription plan). Starting in 2019, people who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.
Medigap in Massachusetts
Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. Nationwide, more than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, private Medigap plans (also known as Medicare supplement plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had only Original Medicare.
In all but three states, Medigap plans are standardized under federal rules. But Massachusetts is one of the three states where a waiver allows the state to design different Medigap plans. In other states, there are ten different Medigap plan designs. But in Massachusetts, there’s just the Medicare Core Plan and the Medicare Supplement 1.
There are nine insurers that offer Medigap plans in Massachusetts in 2020. Blue Cross Blue Shield of Massachusetts also offers a Medicare Select Medigap plan, in addition to the Core Plan and Supplement 1 (Prior to 2006, Massachusetts also had Medicare Supplement 2, which included coverage for prescription drugs; nationwide, all Medigap plans that included prescription drugs ceased to be available for purchase after the end of 2005 — people began enrolling in Medicare Part D instead — but people who had Supplement 2 in Massachusetts were allowed to keep it if they wanted to).
In addition to having different standardization rules for Medigap coverage, Massachusetts has strong consumer protections in the Medigap market. It’s one of eight states where insurers are required to use community rating, which means that premiums cannot vary based on age. Community rating even extends to disabled Medicare beneficiaries under age 65 in Massachusetts. The state also prohibits pre-existing condition waiting periods on Medigap plans (in most states, Medigap insurers can impose pre-existing condition waiting periods of up to six months if the enrollee didn’t have continuous coverage prior to enrolling).
Massachusetts also has an annual Medigap open enrollment period [see 211 CMR 17.10 (5)]. The open enrollment window runs from February 1 to March 31 each year, and gives people a guaranteed-issue opportunity to enroll in Medigap for the first time, if they missed their initial six-month enrollment window, or to switch from one plan to another. This is an unusual provision; people in most states who miss their initial six-month enrollment period or wish to pick a different plan later on do not have another guaranteed-issue opportunity to enroll, unless they qualify for one of the federal government’s very limited guaranteed-issue rights for Medigap.
Under federal Medicare rules, people who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, or if they have ALS or end-stage renal disease. But federal rules do not guarantee access to Medigap plans for people who are under 65. Massachusetts is among the majority of the states that have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Massachusetts requires Medigap insurers to offer coverage to disabled Medicare beneficiaries under age 65, and does not allow insurers to charge those enrollees higher premiums; the state’s Medigap community rating rules extend to disabled beneficiaries as well (this is unusual; while the majority of the states do require Medigap insurers to offer at least some plans to disabled beneficiaries, most states allow them to charge these enrollees higher premiums).
But while most of those states simply require Medigap insurers to offer at least some plans to any Medicare beneficiary under the age of 65, Massachusetts law notes that Medigap insurers are not required to offer coverage to people who are eligible for Medicare due to having end-stage renal disease.
Disabled Medicare beneficiaries have the option to enroll in a Medicare Advantage plan instead of Original Medicare, as long as they don’t have kidney failure. Medicare Advantage plans are otherwise available to anyone who is eligible for Medicare, and the premiums are not higher for those under 65. But as noted above, Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $6,700 per year for in-network care, plus the out-of-pocket cost of prescription drugs.
Medicare Part D in Massachusetts
Original Medicare does not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries nationwide have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.
But Medicare beneficiaries who do not have drug coverage through Medicaid or an employer-sponsored plan need Medicare Part D in order to have coverage for prescriptions. Part D can be purchased as a stand-alone plan, or obtained as part of a Medicare Advantage plan that has integrated Part D coverage. Part D was created under the Medicare Modernization Act of 2003, which was signed into law by President George W. Bush.
There are 26 stand-alone Part D plans for sale in Massachusetts in 2019, with premiums that range from about $14 to $128/month.
718,795 Medicare beneficiaries in Massachusetts had stand-alone Part D coverage as of December 2018. Another 289,189 had Part D prescription coverage as part of their Medicare Advantage plans.
Medicare spending in Massachusetts
Original Medicare’s average per-beneficiary spending in Massachusetts was slightly lower than the national average in 2017, at $9,599. Nationwide, average per-beneficiary Original Medicare spending stood at $9,761. The spending amounts are based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage.
You can read more about Medicare in Massachusetts in our state Medicare guide. You can also contact the SHINE Program (Serving the Health Insurance Needs of Everyone) with questions related to Medicare coverage in Massachusetts.
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.