Commonwealth Choice

What is Commonwealth Choice?

Commonwealth Choice is a health insurance program for uninsured adult Massachusetts residents. The program offers "good value" unsubsidized health insurance to people who are not eligible for MassHealth or Commonwealth Care.

The Commonwealth Health Insurance Connector Authority is in charge of the program. The Connector reviews health plans offered by private insurance companies and approves plans that meet service and cost standards. The Connector also helps residents and employers choose the plan that best meets their needs.

If you have questions about the program, you may call Commonwealth Choice toll-free at 1-866-636-4654 or call the Connector at 1-877-MA-ENROLL (1-877-623-6765).

Am I eligible?

Commonwealth Choice health plans are for Massachusetts residents who are 19 or older and do not qualify for government subsidized health insurance such as Commonwealth Care because their family income is greater than 300% of the Federal Poverty Guidelines.

There are no income or asset limits for the program.

Note: College students living in Massachusetts temporarily are not eligible for the program. People who move out of state cannot keep their Commonwealth Care plan.

What benefits will I get?

All Commonwealth Choice health plans must provide at least the minimum benefits outlined in the Minimum Creditable Coverage (MCC) rules set by the Health Connector. See Minimum Benefits - 2009 for details on 2009 requirements.

All Commonwealth Choice health plans must include:

• preventive and primary care
• emergency care
• hospitalization
• ambulatory patient care
• mental health and substance abuse services
• prescription drug coverage

Minimim Creditable Coverage (MCC) rules for 2009 have these specific requirements:

• Health plans must allow at least 3 regular doctor visits or checkups for an individual, or 6 for a family, before a deductible
• Plans with a deductible must limit the deductible to no more than $2000 per year for an individual or $4000 per year for a family
• If there is a separate prescription drug deductible, it cannot be more than $250 for an individual or $500 for a family
• Out-of-pocket costs for health services must be limited to $5000 for an individual or $10,000 for a family per year
• There can be no cap on benefits per sickness
• There can be no annual cap on benefits
• Coverage of hospital stays cannot be limited to a fixed dollar amount per day or per stay

Some plans also offer extra benefits, like fitness rebates, eyewear discounts, car seats for new parents, or safety helmets. Some plans limit your choice of doctors and hospitals. Young Adult Plans do not have to offer the same benefits (for example, they can have annual maximum benefit caps), but they must provide reasonable coverage.

For more details about plan benefits:

• Compare plans on the Commonwealth Connector web site Commonwealth Connector: Find Insurance

• Call Commonwealth Choice toll-free at 1-866-636-4654 or the Connector at 1-877-623-6765

• Contact the plans directly. See What plans can I choose from?

Do Commonwealth Choice plans cover preexisting conditions?

Commonwealth Choice health plans must provide coverage for preexisting conditions. There are no waiting periods. Your coverage begins as soon as you sign up for a plan and pay your monthly premium.

What plans can I choose from?

You can compare plans that are available to you on the Commonwealth Connector web site Commonwealth Connector: Find Insurance.

Descriptions of plan benefits are also available online at Commonwealth Choice Overview, or in the Commonwealth Choice Gold, Silver, Bronze, and Young Adult Brochures.

These companies offer Commonwealth Choice plans:

• Blue Cross Blue Shield of Massachusetts (statewide)
  Phone: 1-800-422-3545
  Web site: Get Blue: Individual and Family Health Insurance

• Fallon Community Health Plan (FCHP)
  Phone: 1-888-PWR-FCHP (1-888-797-3247)
  TTY: 1-877-608-7677)
  Web site: FCHP: Individual and Family Health Insurance

• Harvard Pilgrim Health Care (HPHC) (statewide)
  Phone: 1-800-208-1221
  TTY: 1-800-637-8257
  Web site: HPHC Products: Buy Direct

• Health New England (HNE)
  Phone: 800-310-2835
  Web site: HNE Plan Selector

• Neighborhood Health Plan (NHP)
  Phone: 1-800-462-5449
  TTY: 1-800-655-1761
  Web site: NHP Commonwealth Choice

• Tufts Health Plan
  Phone: 1-800-957-6596
  Web site: Tufts Health Plan Direct

Each company offers these types of plans:

• Gold plans: higher monthly premiums, but low out-of-pocket costs.
• Silver plans: moderate monthly premiums and moderate out-of-pocket costs.
• Bronze plans: lower monthly premiums, but higher out-of-pocket costs.
• Young Adult Plans: for adults between the ages of 19 and 26. Young adult plans have low monthly premiums and higher out-of-pocket costs. Most have an annual limit on benefits.
   
   All plans include prescription drug coverage.

How much does it cost?

Commonwealth Choice health plans vary greatly in price. The price depends on your age, where you live, and the type of plan you choose. You can get rates for Commonwealth Choice plans:

• on the Commonwealth Connector web site Commonwealth Connector: Find Insurance

• by calling Commonwealth Choice toll-free at 1-866-636-4654 or the Connector at 1-877-MA-ENROLL (1-877-623-6765)

• or by calling the health plans directly and asking for a rate quote. See What plans can I choose from? for phone numbers and web site links.

All plans have monthly premiums. Other costs you may have to pay are:

• Deductible: a dollar amount that you must pay toward your medical costs each year before your health plan starts paying benefits (for example, a $1000 annual deductible) Note: All plans with deductibles cover some office visits and preventive care before you have to start paying your deductible. Plans with prescription drug coverage offer some drugs "pre-deductible" or have a separate lower deductible for prescription drugs.

• Co-payments: a fixed dollar amount that you must pay for each medical service (for example, a $20 copayment for each doctor's visit, or a $10 copayment for each prescription). The health plan pays the rest of the cost.

• Co-insurance: a percentage of the cost that you must pay for each medical service (for example, 35% of hospital bills). The health plan pays the rest.

The total of your deductibles, copayments, and coinsurance is your "out-of-pocket cost." The maximum out-of-pocket cost for any Commonwealth Choice plan is $5000 per individual or $10,000 per family per year. If you reach the maximum, you do not have to pay any fees other than the monthly premiums for the rest of the year unless you have a Young Adult Plan. Young Adult Plans have an annual benefit maximum (usually $50,000).

How do I apply?

To apply, call Commonwealth Choice toll-free at 1-866-636-4654 or the Connector at 1-877-MA-ENROLL (1-877-623-6765), Monday through Friday, 8 AM to 5 PM; or visit the Commonwealth Connector web site Welcome to the Connector!. Commonwealth Choice enrollment began on May 1, 2007 and plans went into effect starting July 1, 2007.

If you have questions about plan benefits or need help choosing a plan, you can also contact the plans directly. See What plans can I choose from? for contact information.

Do I have to buy health insurance?

Massachusetts passed a Health Care Reform Law in 2006 that requires all adult residents age 18 and older to have health insurance. To meet the state's requirements, the insurance must include certain basic benefits known as Minimum Creditable Coverage (MCC). For details about MCC requirements, see 2009 Minimum Benefits on the Commonwealth Connector web site.

Most residents without health insurance must pay a penalty. However, people who cannot afford a health plan, or who qualify for a religious exemption or hardship waiver do not have to pay a penalty.

The Massachusetts Department of Revenue (DOR) and the Commonwealth Connector have online affordability tools:

• The Department of Revenue's Health Care Affordability and Penalty Calculator for 2008 allows you to see if you are subject to a penalty on your state income taxes, and the penalty amount. You will need your completed U.S. Form 1040, 1040A, or 1040EZ to get an official result.

• The Commonwealth Connector has an online Affordability Tool to let you see how much you should be able to pay for a health insurance plan based on your income and family size, and if an affordable plan is available for you.

If you cannot find an affordable plan for your family, you do not have to pay a penalty if you do not have health insurance.

Can I get an exemption or waiver?

Massachusetts residents who can afford health insurance but do not buy it must pay a tax penalty unless they qualify for a religious or hardship exemption, or a waiver.

• You can claim a religious exemption if you have sincerely held religious beliefs that prevent you from buying or having health insurance.

• If you had a financial hardship during the year and filed for a Certificate of Exemption before December 1, you do not have to pay a penalty if you received an exemption. For more information, see Filing a Certificate of Exemption on the Commonwealth Connector web site.

• If you owe a penalty, but you faced a hardship during the year that prevented you from buying health insurance despite your income, you can file an appeal when you file your state income taxes. Instructions are given in the Schedule HC Instructions (PDF). The Connector Authority makes the decisions about appeals.

How much is the penalty for no insurance?

Residents without health insurance face monthly penalties. The penalties add up each month without health insurance, and must be paid at tax filing time. Penalties are based on ½ the cost of the lowest-priced Commonwealth Choice plan available to you.

Penalties vary by age and income, based on percentages of the Federal Poverty Guidelines (FPG).

The 2009 tax penalties are:

You can use the FPG income and household size categories below to see which penalty would apply to you:

For more information, see:

• Health Care Reform Act Penalties for Tax Year 2009 on the Department of Revenue (DOR) web site 
• Health Care Affordability and Penalty Calculator for 2008 on the Department of Revenue (DOR) web site
• Estimate Your 2009 Tax Penalty on the Commonwealth Connector web site

People who cannot find affordable health insurance or who qualify for a religious or hardship exemption or waiver do not have to pay a penalty. See Do I have to buy health insurance? for more information.

How do I avoid a penalty?

Massachusetts residents who can afford health insurance but do not buy it face a tax penalty. For tax years 2008 and later, there are monthly penalties. (See How much is the penalty for no insurance?) Residents who qualify for an affordability exemption, religious exemption, or hardship waiver do not have to pay a penalty.

You must file Schedule HC, Health Care Information, when you file your state income taxes to avoid the penalty. You can download a copy of Schedule HC from the Department of Revenue (DOR) web site: 2008 Schedule HC (PDF) and 2008 Schedule HC Instructions (PDF).

Residents with health insurance use Schedule HC to show that they have coverage. Residents without health insurance use Schedule HC to request an affordability, religious, or hardship exemption.

Schedule HC asks for information about your health insurance coverage:

• If you have private health insurance, your insurance company will send you Form 1099-HC with the information you need.
• If you have government-subsidized health insurance, you must indicate if you have MassHealth, Commonwealth Care, Medicare, or another government health plan.
• If you do not have health insurance, you can claim a religious or affordability exemption, or hardship waiver on Schedule HC.
• If you do not have health insurance or claim an exemption, you cannot take the personal exemption on your state tax return.

For more information about Schedule HC and tax form requirements, see Health Care Reform Information for Individuals on the DOR web site.

The Department of Revenue also has a series of videos to help you understand and fill out Schedule HC: 2008 Schedule HC Health Care Virtual Tour.

Do employers have to offer health insurance?

The Health Care Reform Law requires employers with 11 or more full-time employees to offer a group health plan to their employees and pay a fair share of the monthly premiums. Employers who do not obey this law have to pay a Fair Share Contribution of about $295 per employee per year into the Health Safety Net Trust Fund.

In addition, all employers with 11 or more full-time-equivalent employees must set up a Section 125 plan. A Section 125 plan allows employees to buy health insurance with pre-tax dollars through payroll deduction. This saves employees money, because the cost of monthly premiums is subtracted from taxable income, and employees owe less in federal and state income taxes. Employers who do not obey this law can be charged a Free Rider Surcharge if their employees do not buy health insurance and use the Health Safety Net (Free Care) instead.

For more information about employer requirements, see Employers: Find Insurance and Employer Requirements.

Useful links

1. Health Reform Useful Links
   Links to other web sites with information about Commonwealth Choice and Massachusetts health insurance requirements.

Commonwealth Choice section last updated on 8/14/09