Introduction

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INTRODUCTION

1. PRODUCT TYPES
   
   A Health Maintenance Organization ("HMO") is an entity licensed by the Division of Insurance under the provisions of M.G.L. c. 176G that provides or arranges for the provision of health services (at least reasonably comprehensive physician services, on a non-discriminatory basis, inpatient and outpatient services, emergency health services, and may include chiropractic services, optometric services and podiatric services) to voluntarily enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum. An HMO contracts with specific groups of providers to furnish those health care services specifically covered under an HMO's evidence of coverage.
   
   The following information summarizes the products available by carrier.
   
   
   1. Closed Network Product
      
      A traditional HMO product offering coverage for services provided by in-network providers with out-of-network care covered only in cases where urgent or emergency services are needed. These plans are subject to review according to M.G.L. c. 176G.
      
      
   2. Dual Certificate (also known as "Point-of Service")
      
      Product A dual certificate plan is a two certificate product jointly offered by (1) an HMO licensed according to M.G.L. c. 176G and (2) an indemnity carrier operating under the authority of M.G.L. c. 175, M.G.L. c. 176A or M.G.L. c. 176B. Under this product, the member receives two coverage contracts: an HMO evidence of coverage for services provided by in-network providers and an indemnity policy or subscriber certificate for services provided by out-of-network providers. The HMO plans are subject to review according to M.G.L. c. 176G and the indemnity plans are subject to M.G.L. c. 175, 176A or 176B.
      
      
   3. Insured Preferred Provider Plan ("PPP") Product
      
      An insured preferred provider health plan is a product with coverage for both in-network and out-of-network providers in the same coverage product, but with a financial incentive to receive care from the plan's network of preferred providers. These plans are subject to approval under M.G.L. c. 176I. The evidence of coverage may or may not contain a gatekeeper provision. ¹
   
   
   
2. PRODUCTS BY MARKET TYPE
   
   
   1. Large Group Products
      
      Large group products are offered to employment-based plan sponsors with 51 or more employees. Coverage is typically offered directly to the employer or union local, or to an employee benefit trust established by the employer or union for the purpose of providing group insurance benefits to all eligible group employees or union members on a non-discriminatory basis, without any individual underwriting or rating.
      
      
   2. Small Group Products
      
      Small group products are offered to employment-based plan sponsors, including self-employed individuals, with between one and fifty eligible employees as well as eligible individuals. Carriers offering small group products comply with the benefit, eligibility and rating standards of M.G.L. c. 176J and regulation 211 CMR 66.00. Carriers operating in this market are required to offer each of their small group products to every eligible small group and eligible individual on a guaranteed issue basis.
      
      
   3. Medicare-Eligible Products
      
      Most Medicare HMO plans, whether offered by a Health Maintenance Organization to individuals or through employers' retiree health benefit programs, are based on a contract that the HMO has with the federal government to replace Medicare benefits. A few HMOs offer so-called "Medicare Wraparound" plans, which supplement benefits offered by Medicare rather than replacing them. These plans only provide benefits when a person receives care from the HMO's provider, and are only available to employer groups.

      ¹ From The Managed Care and Group Health Handbook, by Jeff Sadler and Robert E. Parr, CLU, RHU, HIA, a "gatekeeper" is defined as "the physician who directs what care is given, how much care is given, and by whom the care is given." (p. 66) (© 1997, The National Underwriter Company)

      NOTE :

      CERTAIN CARRIERS OFFER HEALTH PLANS WITH ALTERNATE NETWORKS THAT ARE DIFFERENT THAN THEIR STANDARD PROVIDER NETWORK. PLEASE BE SURE TO CALL THE CARRIER DIRECTLY IF YOU HAVE ANY QUESTIONS ABOUT WHETHER A CARRIER'S PROVIDER NETWORK IS SPECIFICALLY AVAILABLE IN YOUR AREA AND WHETHER YOUR PRIMARY CARE PROVIDER, SPECIALIST OR ACUTE CARE FACILITY PARTICIPATES IN THE CARRIER'S NETWORK

      
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