Massachusetts Attorney General Andrea Campbell welcomed the order.

"For years, the defendants preyed on financially vulnerable individuals, deceiving them into buying products they didn't need or couldn't afford," Campbell said. "This order holds the companies accountable."

UnitedHealth said it plans to file an appeal.

"We disagree with the Massachusetts court's latest ruling," the company said in a statement. "The fundamental errors in this ruling compound those already made by the trial court earlier in this case and have resulted in a decision that is clearly unsupported by the evidence and contrary to established Massachusetts law."

Lawyers for the defendants have argued in court pleadings that Massachusetts officials ignored state time limits for filing suits and other procedural rules.

What it means: Campbell's HealthMarkets litigation focused on sales of individual products, not group insurance products or worksite marketing programs.

But Massachusetts makes the pleadings available for free online, and the case shows how officials in the state handle compliance in situations involving health insurance marketing strategies and products outside the scope of the Affordable Care Act major medical insurance rules.

The history: HealthMarkets and predecessor companies were originally known for selling individual major medical insurance products and related products.

Around 2009, when members of Congress were drafting and debating the legislation that created the Affordable Care Act, some advocates of increased government involvement in health care named HealthMarkets and its affiliates as examples of the kinds of companies that health reform should eliminate. Critics said that the companies' products were too limited, confused the buyers and used too little of the premium revenue to provide benefits.

Supporters argued that the companies created products tailored to meet the needs of low-income, underserved customers at a price the customers could afford. They said the ratio of sales and administrative costs to premiums was high because serving those customers was expensive.

Related: Workplace health plan 'gap' coverage: Sales up 6%

After 2014, when most Affordable Care Act product rules took effect, Chesapeake Life focused on writing supplemental health products beyond the scope of the ACA, such as critical illness insurance. HealthMarkets sold the Chesapeake Life supplemental health products alongside major medical insurance coverage from other insurers.

Golden Rule, a UnitedHealth subsidiary, acquired HealthMarkets and its affiliates from a private equity investor group in 2019. The goal was to improve individual specialty insurance operations, according to AM Best, an insurance rating agency.

Suit details: Former Massachusetts Attorney General Martha Coakley negotiated a $17 million settlement with HealthMarkets and HealthMarkets affiliates over health insurance marketing practices in 2009.

Campbell's litigation is part of the case that led to the 2009 settlement.

The complaint and the order give examples of consumers who complained about ending up with supplemental insurance policies they had not intended to buy. The complaint and order do not talk about how HealthMarkets and Chesapeake Life handled claims.

The judge does note that Chesapeake Life paid $5.5 million in benefits to about 500 Massachusetts customers.

The complaint and the order focus mostly on allegations that HealthMarkets and its agents violated state sales and marketing rules.

In the order, the judge cites evidence that HealthMarkets and affiliates:

● Indicated on websites, email signatures and LinkedIn pages that sales reps who were licensed with Massachusetts solely as health insurance agents called themselves "insurance advisors" or "licensed benefits consultants."

● Gave consumers quotes for product bundles that included Chesapeake Life supplemental products along with major medical insurance coverage without indicating that multiple products were involved or that consumers could buy the major medical coverage by itself.

● Gave low-income consumers who qualified for free health coverage quotes for bundles that included premiums for supplemental products, without explaining that the underlying health coverage was free.

● Described health care discount programs using terms such as "premiums," "co-pays" and "carriers" that implied that the programs were insurance.

● Made 4.6% of the critical illness insurance sales to consumers who had no major medical insurance.

● Told prospects that short-term health insurance policies would pay for care from "all doctors," even though the policies did not cover care from behavioral health providers,

HealthMarkets agents who testified during the proceedings said that they persuaded most consumers to buy major medical insurance along with the critical illness insurance policies and warned consumers who purchased only critical illness insurance that it was not the same as major medical insurance.

The defendants noted that HealthMarkets and its agents sold many products, such as dental plans, from outside companies to prospects who wanted alternatives to Chesapeake Life products.

Adam Block, a health economist, testified for the defendants that the ratio of benefits to premiums, or loss ratio, is a poor measure of the value of supplemental insurance products, and that much of the value of the products comes from the purchasers' peace of mind.

The judge described Block's testimony as persuasive and also cited Chesapeake Life's payments on claims as mitigating factors. She also reduced the total amount of penalty payments required by the order because she believed the state had failed to provide enough evidence that some violations, such as sales representatives describing themselves as insurance advisors, had harmed consumers.

The judge described the evidence that the defendants had intentionally led to consumers buying supplemental policies without knowing it was particularly concerning.

Correction: An earlier version described the Massachusetts attorney general's allegations about the HealthMarkets sales representatives' use of titles incorrectly. The sales reps are licensed insurance agents. The attorney general objected to their use of descriptive phrases such as "insurance advisor."