Minimum Requirements for Health Insurance in Massachusetts

In the state of Massachusetts, a law enacted in 2006 became known as the Massachusetts Health Care Reform Law. The law mandates that all adult state residents aged 18 and older must have health insurance. Massachusetts residents who do not receive health insurance coverage through an employer must purchase private health coverage or sign up for a public health plan. To meet the state's minimum requirements, the insurance plan must include basic benefits known as Minimum Creditable Coverage, or MCC.

Routine Medical Care

• In 2010, the Minimum Creditable Coverage standards set by the state of Massachusetts require that health insurance plans provide coverage for all basic medical and surgical care including preventative medical care. This means that regular visits to a primary care physician for wellness checkups and routine doctor's office procedures should be covered under the terms of the health insurance plan. The minimum standards also require that prescribed treatments for mental health conditions and cases of substance abuse are included in coverage. Prescription drug coverage must also be a part of the insurance plan along with approved radiation therapy and chemotherapy treatments prescribed for an illness.

Hospital Care

• A health insurance plan that meets the Massachusetts Minimum Creditable Coverage standards must include adequate coverage for various patient services in hospitals and clinics. Sufficient health insurance coverage should stipulate a provision for routine ambulatory care, inpatient hospitalization for acute care as well as emergency services and procedures. In addition, health insurance plans must cover the cost of outpatient day services and expenses related to anesthesia, blood tests, diagnostic imaging and X-rays, as well as doctor-ordered tests to screen for certain conditions and ailments. Health insurance coverage is also required to provide basic maternity coverage and newborn care for hospital births.

Deductibles

• In addition to providing coverage for routine medical services, Massachusetts health plans are required to meet certain regulations regarding health plan deductibles. MCC compliant health plans are expected to cover the cost of preventative care visits without assessing a deductible. Yearly deductibles for in-network services may not exceed $2,000 for an individual or $4,000 for a family. Prescription drug deductibles cannot exceed $250 per individual and $500 per family. Massachusetts requires no cap on the total payout of benefits for a particular illness, and maximum out-of-pocket expenses for up-front deductibles must be no more than $5,000 per individual and $10,000 per family.