Total Health Maintenance Organization (“HMO”) membership in closed network plans increased by 7,435 members from the end of the 4th quarter of 2011 to the end of the 4th quarter of 2012, a percentage increase of .35%. During this time period, membership in group closed network plans decreased by 59,583 members, while there were increases of 3,045 members in Medicare Advantage closed network plans, 27,691 members in Medicaid closed network plans, and 24,777 members in individual closed network plans. The membership in other Medicare closed network plans decreased by 893 members. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2012, with 23.69% of the market.
|An ("HMO") is an entity licensed by the Division of Insurance ("Division") under the provisions of M.G.L. c. 176G that provides or arranges for the provision of health services to voluntarily enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum that demonstrates to the satisfaction of the Commissioner proof of its capability to provide its members protection against loss of prepaid fees or unavailability of covered health services resulting from its insolvency or bankruptcy or from other financial impairment of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.|
|According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.|
|Membership is identified by the following categories:|
|The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, according to the zip code of the member's primary residence listed on the member record (or subscriber record, if dependent's address is not available); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.|