Plan designs (HMO, PPO, POS, indemnity, HDHP with an HSA), cost sharing, and the federal ACA rules are covered in the national Medical Plans guide. Massachusetts adds an individual coverage requirement, the Health Connector, and its own rules for small-group plans, newborn coverage, early intervention and prompt payment. Group continuation is in the Massachusetts group health guide. Individual policy provisions are in the Massachusetts individual accident and health provisions guide.

The individual mandate and the Health Connector

• Individual mandate (M.G.L. c.111M s.2). Residents 18 and over must obtain and maintain creditable coverage if it is affordable under the Connector board's schedule. A lapse of 63 days or less doesn't count toward the tax penalty.
• Health Connector (c.176Q s.11). When a producer enrolls an eligible small group through the Connector, the chosen health plan pays the producer a commission set by the Connector board.
• MassHealth is the state's Medicaid program for eligible low-income and certain disabled residents (c.118E).

Small-group and individual plans (c.176J)

• An eligible small business has 1 to 50 eligible employees on at least half its working days. An eligible employee works a normal week of 30 or more hours.
• A small-group or individual plan may not exclude an eligible person because of age, occupation, health condition, claims experience or medical condition (s.5).

Required benefits

• Newborns. A policy with dependent coverage covers a newborn from the moment of birth (c.175 s.47C).
• Early intervention. Dependent coverage includes medically necessary early intervention services from birth to age 3, generally without copays, coinsurance or deductibles (s.47C).
• Dependents to 26. Individual family policies must cover children under 26 (s.108(2)(a)(3)).
• Disabled children. Coverage continues past the limiting age for a child who can't support themselves if proof arrives within 31 days.

Claims and underwriting

• Prompt payment (s.108(4)(c)). Claim forms are furnished within 15 days of notice. If a hospital or medical claim isn't paid or explained in writing within 45 days, the insurer owes interest of 1.5% per month, capped at 18% a year.
• No genetic tests. Insurers may not require genetic tests or genetic information to issue hospital and surgical expense coverage (s.108H).
• Blindness and deafness. An insurer may not refuse an individual hospital and surgical policy because the applicant is blind or deaf (s.108A).
• Specified disease policies (211 CMR 146.10). The outline of coverage is delivered before the application is presented.

Coordination of benefits (211 CMR 38)

When a child is covered under both married parents' plans, the plan of the parent whose birthday comes earlier in the year is primary, unless a court decree says otherwise.

Common exam traps

• The individual mandate covers residents 18+. Gaps of 63 days or less are ignored for the penalty.
• A small business has 1 to 50 employees, and full time means 30 hours.
• Newborns are covered from birth. Early intervention runs to age 3.
• Unpaid claims accrue 1.5% per month after 45 days.
• COB for dependent children uses the birthday rule.