Medicare in Massachusetts

Medigap plans are different in Massachusetts — there are only three plan designs (and only two for newly-eligible enrollees), instead of ten.

At a glance: Medicare health insurance in Massachusetts

Medicare enrollment in Massachusetts

1,354,179 people had Medicare in Massachusetts as of September 2020, amounting to about 19 percent of the state’s population.

In most cases, filing for Medicare benefits goes along with retirement and turning 65. But Medicare enrollment is also available to younger Americans after they have been receiving disability benefits for 24 months, or if they have ALS or end-stage renal disease.

Sixteen percent of Medicare beneficiaries in Massachusetts are under the age of 65; nationwide, it’s 15 percent. On the high and low ends of the spectrum, 22 percent of Medicare beneficiaries in Alabama, Arkansas, Kentucky, and Mississippi are under 65, while just 9 percent of Hawaii’s Medicare beneficiaries are eligible due to disability.

Medicare coverage options

Medicare beneficiaries can choose to get their healthcare coverage via Original Medicare, where coverage is paid for directly by the federal government, or they can select a Medicare Advantage plan, in which a private health insurance company contracts with the federal government to provide Medicare benefits to members. Original Medicare beneficiaries also have options around Medigap policies and Medicare Part D prescription drug coverage (Medigap plans aren’t necessary Medicare Advantage plans, and most Advantage plans include integrated Part D coverage for prescription drugs).

Original Medicare includes Part A (also called hospital insurance, which helps pay for inpatient stays at a hospital, skilled nursing facility, or hospice center) and Part B (also called medical insurance, which helps pay for outpatient and physician care). Medicare Advantage plans provide all of the covered benefits of Parts A and B, although the out-of-pocket expenses can be quite different, as Advantage plans set their own copay, coinsurance, and deductible levels, within general parameters established by CMS. Most Advantage plans also provide additional benefits such as Part D coverage for prescription drugs, and extras like dental and vision coverage and gym memberships.

When you’re deciding between Medicare Advantage and Original Medicare, there are pros and cons to either option; the right solution is different for each person.

Medicare Advantage in Massachusetts

Medicare Advantage plans are offered by private insurers, whose service areas vary from county to county. Most of Massachusetts has a very robust Medicare Advantage market, with numerous plans available — more than 40 in many areas of the state. But residents in Dukes and Nantucket counties have just three Medicare Advantage plans available for 2021 (up from just one in 2020).

Twenty-one percent of Massachusetts Medicare beneficiaries were enrolled in Medicare Advantage plans as of 2018. By the fall of 2020, 27 percent of Massachusetts Medicare beneficiaries had Medicare Advantage coverage, mirroring the nationwide increase in Medicare Advantage enrollment (nationwide, about 40 percent of Medicare beneficiaries were enrolled in private plans as of mid-2020, nearly all of which were Medicare Advantage plans). But nearly three-quarters of Medicare beneficiaries in Massachusetts were enrolled in Original Medicare as of 2020.

The popularity of Medicare Advantage plans varies from one state to another. In Minnesota, nearly half of the state’s Medicare population is enrolled in Medicare 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). And people who are already enrolled in Medicare Advantage also have the option to switch to a different Advantage plan or to change 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 medical 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, optional 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.

According to an AHIP analysis, there were 335,911 Massachusetts Medicare beneficiaries enrolled in Medigap coverage as of 2018. That’s up from 304,263 in 2016 and 231,579 in 2013.

There are nine insurers that offer Medigap plans in Massachusetts.

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 Supplements 1 and 1A.

Massachusetts added Medicare Supplement 1A as of 2020; it’s the same as Supplement 1 except that it does not cover the Medicare Part B deductible, which is $198 in 2020. The addition of Supplement 1A was necessary because federal law (MACRA) does not allow people who become eligible for Medicare in 2020 or later to enroll in a Medicare supplement that covers the Part B deductible. So people who were eligible for Medicare in Massachusetts in 2019 or earlier can choose from among all three supplement options, whereas people who become eligible for Medicare in 2020 or later cannot enroll in Supplement 1 (they can choose the Core Plan or Supplement 1A instead).

(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 among the country’s strongest consumer protections for Medigap plans. 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, and as of 2021, this includes people with kidney failure, who were barred from enrolling in most Medicare Advantage plans prior to 2021. Medicare Advantage 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 $7,550 per year for in-network care in 2021, plus the out-of-pocket cost of prescription drugs.

Massachusetts Medicare Part D

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 enrollment in order to have coverage for prescriptions. Medicare Part D plans can be purchased as a stand-alone plan, or obtained as part of a Medicare Advantage plan that has integrated Part D coverage. Medicare Part D was created under the Medicare Modernization Act of 2003, which was signed into law by President George W. Bush.

There are 27 stand-alone Medicare Part D plans for sale in Massachusetts for 2021, with premiums that range from about $7 to $135/month.

727,738 beneficiaries of Medicare in Massachusetts had stand-alone Part D coverage as of September 2020. Another 337,706 had Part D prescription coverage as part of their Medicare Advantage plans. Enrollment in Part D coverage is optional, but people who forego it without having creditable drug coverage from another source will end up paying a late enrollment penalty if they decide to sign up for Part D later in life.

Medicare Part D enrollment is available on an annual basis, during the fall election period (October 15 to December 7). Medicare beneficiaries also have an opportunity to enroll in a Part D plan when they’re first eligible for Medicare, or after another creditable drug plan ends (for example, an employer’s plan that ends when the person retires).

Medicare spending in Massachusetts

Average per-beneficiary spending for Original Medicare in Massachusetts was slightly lower than the national average in 2018, at $10,015. Nationwide, average per-beneficiary Original Medicare spending stood at $10,096. 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.

Per-beneficiary Medicare spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.

How does Medicaid provide financial assistance to Medicare beneficiaries in Massachusetts?

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums, prescription drug expenses, and services Medicare doesn’t cover – such as long-term care.

Our guide to financial assistance for Medicare enrollees in Massachusetts includes overviews of these benefits, including long-term care coverage, Medicare Savings Programs, and eligibility guidelines for assistance.

Resources for People with Medicare in Massachusetts

If you have questions about Medicare eligibility in Massachusetts or Medicare enrollment in Massachusetts, the SHINE Program (Serving the Health Insurance Needs of Everyone) can help.

Massachusetts also maintains a web page devoted to Massachusetts Medicare laws.

The Medicare Rights Center is a nationwide service that can provide a variety of information and assistance with questions related to Medicare eligibility, enrollment, and benefits.


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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