Massachusetts Health Study Guide

Massachusetts health law is not a regional variation on the national theme. Chapter 58 of the Acts of 2006 built an individual mandate, a state exchange and a merged insurance market four years before the ACA — and the Commonwealth kept all of it. A candidate who studies only national material will walk into the state section confidently wrong on the three most heavily tested topics. Let’s fix that.

The individual mandate still exists

The federal penalty is $0. Massachusetts’s is not. M.G.L. c. 111M § 2 remains in force, and the penalty is real money, scaled to income as a percentage of the federal poverty level. For tax year 2026 it runs from $0 at or below 150% FPL up to $211 a month — $2,532 a year above 400% FPL.

To satisfy the mandate, coverage must meet Minimum Creditable Coverage (MCC) standards set by the Health Connector. MCC is a Massachusetts-only concept and a favourite exam term: it is the floor a plan must clear to count, not merely any coverage at all.

The Connector and the merged market

Massachusetts runs a state-based exchange — the Massachusetts Health Connector, created by c. 176Q — not the federal marketplace. Its open enrollment runs longer than the federal window: for the 2026 plan year, November 1, 2025 through January 23, 2026, against the federal January 15.

The structural oddity is the merged market. Under c. 176J, Massachusetts pools non-group and small-group risk together — very few states do this. And its definition of small group starts lower than most: 1 to 50 eligible employees, counted on at least 50% of working days during the preceding year.

Medicare supplement: Massachusetts is a waiver state

This is the biggest single divergence in the whole section, and it is worth more points than anything else on this page. National courses teach plans A through N, a one-time six-month Medigap open enrollment beginning at 65 and Part B enrollment, and a permitted six-month preexisting condition exclusion.

All three are wrong in Massachusetts.

• Three plans only: Medicare Supplement Core, Supplement 1 (open only to those eligible for Medicare before 1/1/2020), and Supplement 1A. Not the federal lettered plans.
• Annual open enrollment, February 1 through March 31, for coverage effective June 1. Many carriers additionally elect continuous open enrollment with the Commissioner’s approval.
• Guaranteed issue, with no discrimination on age, health status, claims experience, medical condition or genetic information — and no preexisting condition waiting period or exclusion at all.
• 30-day free look from delivery.

Authority: 211 CMR 71.00, implementing c. 176K.

Continuation: mini-COBRA fills the gap under 20

Federal COBRA starts at 20 employees. Massachusetts mini-COBRA (c. 176J § 9) covers the groups underneath: employers with 2 to 19 employees.

The mechanics track COBRA closely, which makes the employer-size threshold the thing to memorise: 18 months for termination or reduction in hours, 36 months for death, divorce or legal separation, Medicare eligibility, or a dependent child ageing out, and 29 months on a Social Security disability determination. Election period: 60 days. Premium: up to 102% of the group rate, rising to 150% during the disability extension months.

Claims: 45 days, paper or electronic

Under the preferred provider arrangements statute, c. 176I § 2, Massachusetts sets a clean-claim payment deadline of 45 days — and unlike many states, it does not split the deadline between electronic and paper claims. Both get 45 days. Interest runs at 1.5% per month (up to 18% a year) from day 45 on a clean claim not timely paid.

External review is worth one more line: the independent review decision binds the carrier, is administered by the Office of Patient Protection, and is due within 45 days under c. 176O § 14 — or 72 hours on an expedited review under the same chapter.

Long-term care

Carrier-provided product training is required before you may sell LTC (211 CMR 65.08), and the policy carries at least a 10-day free look. Massachusetts is not a Long-Term Care Partnership state, so there is no partnership-specific training to complete. It does, however, run its own asset-protection route: 211 CMR 65.06(4) requires a carrier to make available at least one policy meeting the MassHealth standard, and M.G.L. c. 118E § 33 bars a MassHealth claim for long-term care costs where the individual held insurance meeting 211 CMR 65.00. Partnership, no; asset protection, yes.