Report to the
Massachusetts Legislature:
Activities and
Accomplishments of
the Massachusetts
Marketplace
Fiscal Year 2023
Massachusetts Health Connector
2024
Contents
Tables and Figures............................................................................................................. 2
Preface................................................................................................................................ 3
Executive Summary ........................................................................................................... 4
1.0: Introduction ................................................................................................................ 5
2.0: Policy Updates ............................................................................................................ 5
3.0: Non-group Membership ............................................................................................. 8
4.0: Small-group Membership ........................................................................................ 15
5.0: Dental Membership ................................................................................................. 19
6.0: Administration and Operations ............................................................................... 21
7.0: Outreach, Assistance, and Education .................................................................... 23
8.0: Policy and Regulatory Responsibilities ................................................................... 26
9.0: Conclusion ................................................................................................................ 28
Appendix ........................................................................................................................... 30
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Tables and Figures
Table 1. Impact of IRA Extension of Enhanced APTCs ................................................................ 6
Figure 1. Massachusetts Non-Group Membership by Exchange Use, March 2023 ................. 9
Figure 2. Massachusetts Health Coverage by Insurance Type, 2022-2023 ........................... 10
Figure 3. Unsubsidized Non-Group Enrollment by Marketplace Use, 2016-2022.................. 11
Table 2. ConnectorCare Plan Types by Income ......................................................................... 12
Figure 4. ConnectorCare Enrollment by Plan Type, July 2023 (n=136,753)........................... 12
Figure 5. ConnectorCare Enrollment by Carrier, July 2023 (n=136,755) ............................... 12
Figure 6. Non-ConnectorCare Enrollment by Metallic Tier, July 2023 (n=87,453) ................. 13
Figure 7. Non-ConnectorCare Enrollment by Carrier, July 2023 (n=87,453) .......................... 13
Table 3. Health Connector Member Demographics: ConnectorCare vs. Non-ConnectorCare14
Figure 8. Health Connector Members by Race .......................................................................... 15
Figure 9. Health Connector Members by Ethnicity .................................................................... 15
Figure 10. Massachusetts Small-group Enrollment by Exchange Use, March 2023 .............. 16
Figure 11. HCB Small-group Enrollment by Choice Model, July 2023 (n=12,521)................. 16
Figure 12. HCB Small-group Enrollment by Metallic Tier, July 2023 (n=12,521) ................... 17
Figure 13. HCB Small-group Enrollment by Carrier, July 2023 (n=12,521) ........................... 17
Figure 14. Small-group Enrollment On- and Off-Exchange by Carrier, March 2023 ............... 18
Figure 15. ConnectWell Activities ............................................................................................... 19
Figure 16. Non-group Enrollment by Health and Dental Plan, July 2023 (n=256,031) ......... 20
Figure 17. Non-group Dental Enrollment by Benefit Tier, July 2023 (n=122,155)................. 20
Figure 18. HCB Small-group Dental Enrollment by Carrier, July 2023 (n=5,315) .................. 20
Figure 19. HCB Small-group Dental Enrollment by Benefit Tier, July 2023 (n=5,315) .......... 20
Table 4. FY23 Health Connector Programmatic Budget ........................................................... 21
Table 5. FY23 Appeal Requests .................................................................................................. 23
Figure 20. Uninsurance at the Time of Survey for Massachusetts, 2008-2021, CHIA 2021
MHIS ............................................................................................................................................. 25
Table 6. Penalty Schedule for Failure to Comply with the Individual Mandate, 2020-2022 . 28
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Preface
Massachusetts has an extensive history of health care reform efforts aimed at expanding health
insurance coverage to its residents. The Massachusetts Health Connector is proud to be a key part
of the public interest legacy created when the Commonwealth’s landmark health reform law, Chapter
58 of the Acts of 2006, was passed and included a state-based Marketplace: a place where
individuals, families, and small businesses can find, compare, and enroll in affordable health
insurance coverage. As a result of that legacy, Massachusetts has the highest rate of insurance in
the country, with over 97 percent of residents insured.
The work of the Health Connector and the sustained success of health reform in Massachusetts has
benefited from the support and assistance of the Legislature and many state agencies. The Health
Connector would like to thank the Office of the Governor, the General Court, the Executive Office of
Health and Human Services, MassHealth, the Executive Office for Administration and Finance, the
Division of Insurance, the Group Insurance Commission, the Department of Revenue, the Executive
Office of Technology Services and Security, the Center for Health Information and Analysis, the
Department of Public Health, the Division of Unemployment Assistance, the Massachusetts Board of
Higher Education, the Health Policy Commission, the Office of the Attorney General, and the
Massachusetts Office of Business Development. Collaboration across these entities enriches
Massachusetts health reform, and the Health Connector appreciates these partnerships.
The Health Connector is governed by a Board of Directors consisting of 11 members. The staff of the
Health Connector wishes to extend its deepest gratitude to all past and current Directors for their
commitment to health reform. Directors who served in Fiscal Year 2023 (FY23) included:
▪ Marylou Sudders replaced by Kathleen E. Walsh (January 2023), Chair of the Board, Secretary of
the Executive Office of Health and Human Services;
▪ Michael Heffernan replaced by Matthew Gorzkowicz (January 2023), Secretary of the Executive
Office for Administration and Finance;
▪ Gary Anderson, Commissioner of the Division of Insurance;
▪ Matthew Veno, Executive Director of the Group Insurance Commission;
▪ Michael Chernew, Ph.D., Leonard D. Schaeffer Professor of Health Care Policy at Harvard
Medical School;
▪ Filaine Deronnette, Vice-President at Large of 1199 SEIU MA;
▪ Mark S. Gaunya replaced by Eric Gulko (December 2022), President of Innovo Benefits Group;
▪ Keisha O’Marde-Jack (Resigned May 2023), Chief Human Resources Officer at Upstream USA;
▪ Dimitry Petion, President and CEO of Mulberry Systems, Inc.;
▪ Nancy Turnbull, Senior Lecturer on Health Policy and Associate Dean at Harvard School of Public
Health; and
▪ Rina Vertes, President of Marjos Business Consulting.
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Executive Summary
During Fiscal Year (FY) 2023, spanning from July 1, 2022, until June 30, 2023, lingering effects of
the COVID-19 pandemic continued to impact the Health Connector’s work and associated policy
responses. Throughout 2022 and 2023, economic changes and federal policies resulted in
enrollment changes for the Health Connector. In response to the Medicaid continuous coverage
requirement ending on March 31, 2023, the Health Connector’s top priority for FY23 was to design
and implement strategies to ensure residents losing eligibility for Medicaid (MassHealth) were aware
of changing eligibility requirements and able to maintain health insurance coverage and would have
the support they needed to enroll in Health Connector or other sources of health coverage. In
addition to the Health Connector’s outreach and programmatic planning, passage of the Inflation
Reduction Act (IRA) in August 2022 extended enhanced Affordable Care Act (ACA) premium
subsidies, providing crucial affordability support to individuals in purchasing Health Connector
coverage through 2025.
In May 2023, the Health Connector Board voted to amend Minimum Credible Coverage (MCC)
regulations to specify that no-cost high-value preventive services must be included in coverage for
residents to avoid paying a tax penalty under the state’s individual mandate. MCC amendments were
proposed in response to Braidwood Management v. Becerra, a lawsuit that challenges ACA
requirements covering preventive care services. While MCC does not apply to health plans directly,
plans often choose to meet MCC standards so enrolled members are not faced with individual
mandate tax penalties. Amending MCC regulations bolstered robust coverage of affordable and
accessible preventive services to all adult Massachusetts residents.
The Health Connector ended FY23 with 224,206 non-group medical plan enrollees and 12,521
small-group medical plan enrollees. Compared to the end of FY22, the Health Connector experienced
a 1.6 percent decrease in non-group membership and a 10.4 percent increase in small group
membership. The non-group membership decrease is largely attributable to the Medicaid continuous
coverage requirement associated with the COVID-19 pandemic that temporarily suppressed typical
enrollment dynamics for the Health Connector. The Health Connector’s continued position as a
source of high-quality and affordable health coverage in the state, even as broader dynamics
temporarily altered its enrollment, is a result of the strategic approaches it took in FY23:
▪ The Health Connector engaged in broad-based outreach to generate awareness of the end of the
Medicaid continuous coverage requirement beginning on March 31, 2023, to assist residents
experiencing changes in eligibility status.
▪ The Health Connector raised awareness of the availability of increased federal subsidies for
health insurance purchased through ACA Marketplaces through 2025.
▪ The ConnectorCare program provided low-to-moderate income residents with affordable health
coverage with low or no cost sharing and no deductibles. Premiums increase gradually with
income, with plans as low as $0 a month for those with incomes up to 150 percent of the FPL
and $137 a month for those at 300 percent of the FPL. (Of note, beginning in 2024, the
ConnectorCare Pilot expansion raises income eligibility from 300 to 500 percent of the FPL,
effective through 2025. The Health Connector will monitor pilot implementation and impacts
through FY24 and include details in the FY24 Annual Report for the Legislature.)
▪ The Health Connector continued to address health inequities through its Seal of Approval (SOA)
plan design and certification process by eliminating cost sharing for certain medications related
to chronic illness disproportionately borne by communities of color for ConnectorCare members
in 2023.
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▪ Health Connector for Business continued to offer Massachusetts businesses with up to 50
employees a way to provide flexible benefit options in health insurance plans as well as premium
rebates for participating in a wellness program. The Health Connector uses multi-channel
outreach strategies including paid media, event participation, and close relationships with
brokers to promote Health Connector for Business to small businesses across the
Commonwealth.
Health Connector staff spent the latter portion of FY23 collaborating on a refined strategic plan for
2024-2028, to review existing approaches to supporting the diverse needs of state residents who
depend on Marketplace coverage. The 2024-2028 strategic plan provides a clear and measurable
pathway for future policy, programmatic, and operational improvements to deliver high value
coverage across the Commonwealth. The Health Connector continues to strive to improve the
applicant and member experience, respond to and resolve customer issues at the member and
operational levels, and enhance approaches to equitable health insurance coverage.
The Health Connector will continue to build on its 18-year legacy of providing residents of
Massachusetts with access to high-quality health insurance, responding to consumer needs and an
ever-evolving policy and market landscape. The Health Connector looks forward to working with
stakeholders to help Massachusetts to continue to lead the nation in health reform and coverage
expansion.
1.0: Introduction
1.1: History of the Health Connector
In Massachusetts, Chapter 58 of the Acts of 2006, the state’s landmark health reform law, and the
Health Connector were built on the understanding that access to affordable and comprehensive
coverage is a fundamental need of all Commonwealth residents. Since its creation, the Health
Connector has maintained an essential role in the Massachusetts merged non-group and small-
group market, including through the state’s transition to the federal Patient Protection and
Affordable Care Act (ACA), which became law in 2010 and was largely implemented between 2014
and 2015.
Through that transition, Massachusetts continued its commitment to keeping insurance affordable
for low-income individuals and created the ConnectorCare program to supplement federal subsidies.
ConnectorCare provides additional support to members to reduce both premiums and out-of-pocket
costs at the point of service, such as co-pays. Historically, the program has served Health Connector
members with income under 300 percent of the Federal Poverty Level (FPL), which is around
$40,770 a year for an individual, or $83,250 for a family for 2023 plans. ConnectorCare has been
critical to preserving coverage gains made in Massachusetts prior to the ACA and driving competition
that helps keep premiums stable and low-cost in the merged market. See Appendix A for a timeline
of milestones in Massachusetts market reform.
2.0: Policy Updates
2.1 Extension of ARP’s Enhanced Subsidies through the IRA
Enhanced federal premium subsidies continue to increase affordability of health coverage for
individuals and families in Massachusetts in FY23. The American Rescue Plan Act (ARP) was signed
into law in March 2021 and included enhanced and expanded premium subsidies available through
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state-based Exchanges like the Health Connector. While ARP’s expansion of APTCs was originally set
to expire at the end of 2022, the Inflation Reduction Act (IRA), signed into law by President Biden on
August 16, 2022, included a three-year extension of the enhanced ACA premium tax credits through
2025. These federal premium subsidy enhancements represent the most significant federal
expansion of coverage and affordability since the ACA was passed and have increased affordability
for hundreds of thousands low- and moderate-income residents across the Commonwealth.
Approximately two-thirds of Health Connector members had lower premiums on their bills in FY23
than they would have without these enhanced subsidies.
High impact provisions of the ARP and IRA in effect for 2021 through 2025 include:
1. Expansion of APTC generosity: Through 2025, expanded federal Advance Premium Tax Credits
(APTC) enhance generosity for households with incomes under 400 percent FPL (about $54,360
for an individual or $111,000 for a family of four in 2023) in a manner that more closely mirrors
the level of support that Massachusetts has provided for over a decade through state subsidies.
2. Expansion of APTC eligibility: Through 2025, there is no income “cap” on receiving APTCs,
making subsidies available to households with incomes above 400 percent FPL for the first time.
This ensures that a family’s contribution towards a benchmark plan premium will not exceed 8.5
percent of their household income.
Extension of these enhanced subsidies has made coverage more affordable for nearly 200,000
Massachusetts residents, particularly given heightened costs of household goods and services. This
extension brought about $160M-$175M additional APTC support into the state for the purpose of
premium affordability in 2023 alone. In FY23, Massachusetts residents saved hundreds of dollars
per month on Health Connector plans. All subsidized Health Connector enrollees are receiving more
tax credits because of ARP (Table 1).
Table 1. Impact of Enhanced APTCs
Premium Savings for Massachusetts Residents in 2023 Due to Enhanced
Premium Tax Credits
ConnectorCare Up to $29/month
APTC eligible enrollees above 400 Average of $219/month
percent FPL
Source: Health Connector September 2022 Board Presentation. Federal Policy Updates.
https://www.mahealthconnector.org/wp-content/uploads/board_meetings/2022/09-08-22/Policy-Updates-090822.pdf.
2.2 The End of the Federal Public Health Emergency (PHE) and Medicaid Protections
The Families First Coronavirus Relief Act (FFCRA) directed Medicaid agencies to keep all enrollees
covered for the duration of the federal COVID-19 Public Health Emergency (PHE) which began in
January 2020. The population protected in the Commonwealth’s Medicaid program, MassHealth,
included individuals who reported eligibility changes that would normally make them ineligible for
MassHealth and instead qualify them for Health Connector coverage. The Consolidated
Appropriations Act, passed in December 2022, delinked the Medicaid continuous enrollment
provision from the end of the PHE. As a result, the continuous enrollment provision ended on March