By the Division of Insurance
Membership by HMO by county:
Total Health Maintenance Organization (“HMO”) membership in closed network plans increased by 13,530 members from the end of the 3rd quarter of 2013 to the end of the 4th quarter of 2013, a percentage increase of .6% . During this time period, membership in group closed network plans decreased by 1,400 members, as well as an increase of 9,094 members in Medicaid closed network plans, while there were increases of 792 members in Medicare Advantage closed network plans and 4,317 members in individual closed network plans. The membership in other Medicare closed network plans increased by 262 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 2013, with 23.8% 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:
- Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.
Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.
- Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
- Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
- Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
- Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
- Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.