Please explain Massachusetts Insurance Mandate
Insurance coverage is sometimes confusing. Refusal of coverage can be related to medical criteria established by the insurer or how the employer has set up the insurance plan. The MA mandate, Chapter 17A: Section 8K. Infertility diagnosis and treatment benefits, can be found using this link: http://www.mass.gov/legis/laws/mgl/176a-8k.htmThe mandate to cover infertility services applies to “individual or group hospital service” plans. Excluded from the mandate are “Self insurance health plan(s)” also commonly known as “Self Funded” plans. These are options available to employers when setting up the insurance coverage they choose. The definition of self funded plans according to MA Law is:
“… a plan which provides health benefits to the employees of a business, which is not a health insurance plan, and in which the business is liable for the actual costs of the health care services provided by the plan and administrative costs.”
What does that mean? If your employer has self funded the insurance plan they are responsible for paying all health care claims. The insurance company acts as a middle man between the employer and the health care providers. So, for example, RSC will send a bill to your insurance for services provided. The insurance will review the bill against the policy certificate which outlines what is covered and the contract with the provider outlining how much to pay. The insurance company will then send this information to the employer who will write the check for the services payable through the insurance company. All payments come directly out of the employer’s pocket, not the insurance companies, making the employer directly responsible / liable for high claim years.
Under an “individual or group hospital service plan” the employer pays premiums to the insurance company based on historical data from past claim years and the population of employees to be insured. Claims are received from health care providers and they are processed and paid out of the insurance company’s pocket. This puts the insurance company, not the employer, at risk for high claim years, which can sometimes lead to higher premiums at renewal time.
You have asked, “Does the insurance company have to be in Mass or is it good enough that I am living in Mass with coverage?” The answer is yes and no. If your insurance is self funded by your employer they have the option to cover infertility, exclude infertility or set any dollar or cycle limit they see fit. In other words, you may not have coverage under the mandate. If your insurance is an individual or group hospital service plan then you should have coverage as a resident of Massachusetts no matter where the insurance company is based.
If your plan is self funded and you do not have the benefit you may want to look into coverage through your partner’s employer.
If you have questions about coverage for your fertility treatment, feel free to call and talk with an RSC New England Financial Services representative at (781) 674-1206.
