Chapter 58 Sections

Section 3 (Part 6): Health Disparities Council

Creates a Health Disparities Council within EOHHS to make recommendations to reduce racial and ethnic health disparities in the Commonwealth and to increase diversity among healthcare workers.

Section 6: Health Care Access Bureau

Creates a new Health Care Access Bureau within the Division of Insurance with responsibility for oversight of the small group and individual health insurance market and affordable health plans, funded by a $600,000 annual assessment on insurance carriers.

Section 8 (Part 1): Commonwealth Care Trust Fund

Creates a Commonwealth Care Trust Fund that will receive revenue generated from the Fair Share Contribution, the Free Rider Surcharge, and other revenue that will be used to pay for subsidized health insurance and Medicaid rate increases.

Section 12 (Part 1): Individual Mandate Definitions

Chapter 111M provides for the individual mandate to have health insurance coverage. Section 1 provides definitions of "creditable coverage," which also provides that the board of the Connector has authority to further determine "minimum creditable coverage" standards for individual and group health plans; and defines "resident" for purposes of the individual mandate.

Sections 12 & 13: Individual Mandate Requirement

Establishes the procedure for implementation of the individual mandate. Qualifying individuals for whom "creditable coverage" is deemed affordable must have "creditable coverage" in place. Individuals must include information about health insurance status on their tax forms. Failure to meet the insurance requirement will result in a penalty, assessed by the department of revenue. All penalties will be deposited in the Commonwealth Care Trust Fund that will contribute to state subsidies for the Commonwealth Care program. • Creates a penalty for non-compliance with the individual mandate as equal to 50% of the lowest premium available for each month the individual did not have creditable insurance, as determined by the Connector.

Sections 15, 16, 17 & 18: MassHealth Eligibility

Expands MassHealth eligibility for children up to 300% of the Federal Poverty Level, increased from the previous 200% of the Federal Poverty Level. • Prevents MassHealth from establishing disability criteria for determining eligibility that is more restrictive than the federal Social Security standards. • Establishes MassHealth eligibility standards for people with HIV at 200% of the Federal Poverty Level. • Requires the Office of Medicaid to provide statements of coverage to enrollees and verify coverage to the commissioner of revenue.

Sections 19, 20, 21, 22 & 23: Insurance Partnership Eligibility

Expands employee eligibility for participation in the Insurance Partnership Program to 300% of the Federal Poverty Level. • Ensures that Insurance Partnership subsidies are consistent with those provided under the Commonwealth Care program. • Specifies that self-employed individuals enrolled in the Insurance Partnership Program are eligible for employee subsidies only.

Section 29 (Part 1): MassHealth Adult Benefits

Restores all MassHealth adult benefits cut in 2002, including dental, vision, chiropractic, and prosthetics, effective July 1, 2006. (Note: This section was partially superseded by a provision in the FY 2011 budget authorizing reduction of dental benefits to adults in MassHealth.)

Section 30 (Part 2): Health Safety Net Office

Creates Health Safety Net Office to replace current Uncompensated Care Pool administration. The Health Safety Net pays acute care hospitals and community health centers for certain essential services provided to uninsured and underinsured Massachusetts residents.

Section 41: Hospital Cost and Utilization Reports

Requires hospitals to conduct uniform reports to the Division of Health Care Finance and Policy, which must include the names and addresses of employers whose employees receive free care at the hospitals. Amended in 2010 to also require public and private insurance providers to submit to the Division of Health Care Finance and Policy an explanation of charges and costs associated with group and individual insurance plans.

Section 42 (Part 1): Health Safety Net Eligibility

Requires applicants for the Health Safety Net to be enrolled in other publicly-funded health programs, if eligible. Applicants deemed ineligible for such programs are required to provide the name and address of their employer and their own identifying information, including social security number.

Section 44: Employer Free Rider Surcharge

Sets out provisions governing assessment of Free Rider surcharge on certain employers who do not offer health benefits to their employees based on the number of employees, the use of the Free Care Pool, total state-funded costs, and the percentage of employees enrolled in the employer’s health plan.

Section 45 (Part 3): Commonwealth Care Eligibility

Sets eligibility standards for the Commonwealth Care health insurance program, which provides subsidized insurance to people with incomes under 300% of the Federal Poverty Level who are not eligible for other publicly-funded programs. Subsidies will be paid based on a sliding scale for eligible plans that are procured by the Connector. Subsidies are not available to workers who are provided coverage by their employers; however, the Connector may waive that restriction.

Section 47: Employer Fair Share Contribution

Creates the Fair Share Contribution, to be paid by employers who do not provide or make a reasonable contribution to health insurance for their employees. The contribution requirement applies to employers with 11 or more employees and is capped at $295 annually per employee.

Section 52: Prohibit Employer Coverage Discrimination

Provides that Blue Cross plans may only offer policies to employers if the insurance is offered to all full-time employees. The employer must offer to cover the same premium contribution percentage for each employee but may allow greater contribution percentages to lower paid employees and separate percentages for employees with collective bargaining agreements.

Section 55: Prohibit Employer Coverage Discrimination

Blue Cross Blue Shield may only offer coverage to employers if the insurance is offered to all full-time employees. The employer must offer to cover the same premium contribution percentage for each employee but may allow greater contribution percentages to lower paid employees and separate percentages for employees with collective bargaining agreements.

Section 59: Prohibit Employer Coverage Discrimination

Provides that an HMO may only sell a group health plan to employers if the insurance is offered to all full-time employees. The employer must offer to cover the same premium contribution percentage for each employee but may allow greater contribution percentages to lower paid employees and separate percentages for employees with collective bargaining agreements.

Section 6A: Health Care Access Bureau Database

Establishes a database within the Health Care Access Bureau to track insurance coverage for purposes of complying with the individual mandate. All insurers must report monthly coverage to the Bureau for this database and the information will be shared with DOR.

Section 81: Merged Non-Group and Small Group Insurance Markets

Allows individuals to purchase coverage through the small group insurance market, and provides that the small group insurance law provisions apply to all small business and individual plans issued by an insurance carrier, by the Connector, or through an intermediary.

Section 82: Permitted Premium Rate Factors

Sets the factors used to set premiums for the merged individual and small group market. This section establishes a maximum rate band range from .66 to 1.32 for the following factors: age, industry rate, participation-rate rate, wellness program rate, and tobacco use rate. Additionally, carriers can apply only the following factors outside the rating band in establishing premiums: benefit level, geographic region, adjustment factor for an eligible individual and a small group, and group size. Additionally, requirements are laid out for which carriers with 5,000 or more members will be required to file a plan annually with the Connector to be considered for the "Connector Seal of Approval."

Section 83: Private Insurance Requirements

Requires insurance carriers to make available to individuals and small groups information for all plans and prices of plans offered to any other individuals and small groups. • Modifies the current requirement of carriers to make health benefit plans available in the following ways: Requires carriers to offer coverage effective within 30 days after application to any eligible individuals if they request coverage within 63 days of any prior creditable coverage. If the 63 day period has lapsed, carriers must offer coverage effective on the first day of the month following enrollment to eligible individuals who apply during the mandatory biannual open enrollment periods. • For a Trade Act/Health Coverage Tax Credit Eligible Individual, carriers may impose a 6 month exclusion of coverage for pre-existing conditions if the individual had less than 3 months of continuous coverage before becoming eligible for the tax credit or had a break in coverage for more than 62 days before applying for the plan. However, plans offered to individuals without creditable coverage for 18 months prior to application may not be subjected to a waiting period. • A carrier can deny enrollment in any plan if the carrier files with the Commissioner proof of intent to stop selling that plan. • Carriers can require individuals or groups of 1-5 to enroll in plans via the Connector or an intermediary.

Section 84: Prohibit Insurance Premium Discrimination

Prevents insurance policies from excluding individuals based on age, occupation, health condition, claims experience, duration of coverage or medical condition. • Prevents insurance policies from excluding for more than 6 months preexisting conditions that were medically diagnosed or treated. Pregnancy existing on the date of enrollment is not included as a preexisting condition. • Plans offered to Trade Act/Health Coverage Tax Credit Eligible Persons may not include a waiting period or a pre-existing condition exclusion.

Sections 85 & 86: Division of Insurance Rate Review

Provides that the Commissioner of the Division of Insurance may approve, according to established criteria, health insurance policies for individuals or small businesses that cover more restricted networks that differ from the overall carrier's network. The Commissioner may also disapprove any proposed rate changes if the Commissioner disapproves proposed rate increases to a small group plan, an insurance carrier must notify all members of the plan that the proposed increase has been disapproved and is subject to a public hearing. The carrier may not implement the proposed rates until the Commissioner has approved the rates.

Section 87: Insurance Group Size Adjustment

Requires insurance carriers to disclose to prospective small business customers the surcharge that may be applied to the group’s premium and the participation requirements or participation rate adjustments for each health plan. • Requires insurance carriers to file electronically with the Division of Insurance rates and notification of actuarial methodology and any relevant changes prior to filing.

Section 89: Continuous Coverage Eligibility

Adds "eligible individuals" to those who do not qualify for "continuous coverage" under the state's mini-COBRA law due to the employer having only one or more than nineteen employees.

Section 90: Young Adult Plans Regulations

Establishes insurance plan coverage criteria for Young Adults to be set by Division of Insurance. Only individuals between 19 & 26 who do not have employer-sponsored coverage are eligible for these products. Only insurance carriers with 5,000 or more enrollees may offer Young Adult plans, and the plans must be offered through the Connector.

Sections 93 & 94: Waiting Periods Allowed If Break In Coverage

Prevents insurance carriers from excluding an eligible individual or an eligible dependent, who applied for a health plan within 63 days of termination of prior creditable coverage, from a plan or impose a pre-existing condition exclusion or waiting period in any health plan if the individual meets the following criteria: the individual had 18 or more months of continuous credible coverage before applying, is not eligible for a group plan, and does not have other health insurance coverage. If an eligible individual does not meet the above-mentioned criteria, a carrier may subject the individual to a 6 month waiting period for pre-existing conditions with the exception of emergency services.

Sections 97 to 100: Prohibit Insurance Premium Discrimination

Prevents insurance policies from excluding individuals based on age, occupation, health condition, claims experience, duration of coverage or medical condition. • Establishes a maximum waiting period on an individual to 4 months, with the exception of emergency services, for pre-existing conditions that were medically diagnosed or treated only if the individual has been without creditable coverage for more than 18 months before enrolling in the health plan. Late enrollees may not be excluded from a health plan for more than 12 months. • Pregnancy existing on the date of enrollment is not included as a preexisting condition.

Section 101 (Part 2): Establish Health Connector

Establishes the Connector as an authority within the Executive Office of Administration and Finance. Establishes the governance of the Connector by the 10-member board, chaired by the Secretary of Administration and Finance. The board is made up of 4 state officials and 6 citizens.

Section 101 (Part 3): Connector Board Authority

Authorizes the Connector Board to offer insurance products to individuals and small businesses, publish a schedule for premiums at which individuals of varying ages are eligible, and establish a schedule for affordability to be used in enforcing the individual mandate based upon percentage of income eligible to be spent on health care.

Section 104: Outreach and Enrollment Grants Criteria

Provides outreach and enrollment grants to community and public and private nonprofit groups, located in areas with high percentages of uninsured individuals, that provide enrollment assistance, education, and outreach programs to individuals who may be eligible for MassHealth or other subsidized health plans.

Section 110: Community Health Workers Study

Requires the Department of Public Health to investigate the funding of community health workers to increase overall access to health care, and eliminate health disparities among vulnerable populations.

Section 112: MassHealth Waiver Amendment

Requires the Commonwealth to request an amendment to the MassHealth demonstration waiver to implement Chapter 58 of the Acts of 2006 and to seek maximum federal reimbursement available for subsidized health insurance programs.