By the Division of Insurance
Membership by HMO by county:
Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 31,100 members from the end of the 3rd quarter of 2016 to the end of the 4th quarter of 2016; a percentage decrease of 1.38%. During this time period, membership in group closed network plans decreased by 8,262 members; membership in Medicare Advantage closed network plans increased by 233 members; membership in other Medicare closed network plans decreased by 154 members; membership in closed network Medicaid plans decreased by 27,413 members; membership in closed network individual plans increased by 4,496 members; and membership in other closed network plans remained at zero. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of insured members in closed network plans at the end of the 4th quarter of 2016.
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.
- 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 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.
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 6.1" 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.