Membership by HMO by county:
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Membership Trend pdf format of 1q06Dist_trend.pdf
Membership Trend pdf format of 2q06Dist_trend.pdf
Membership Trend pdf format of 3q06Dist_trend.pdf
Membership Trend pdf format of 4q06Dist_trend.pdf
Total Members pdf format of 1q06Dist_total.pdf
Total Members pdf format of 2q06Dist_total.pdf
Total Members pdf format of 3q06Dist_total.pdf
Total Members pdf format of 4q06Dist_total.pdf
Group Members pdf format of 1q06Dist_group.pdf
Group Members pdf format of 2q06Dist_group.pdf
Group Members pdf format of 3q06Dist_group.pdf
Group Members pdf format of 4q06Dist_group.pdf
Medicare Choice Members pdf format of 1q06Dist_choice.pdf
Medicare Choice Members pdf format of 2q06Dist_choice.pdf
Medicare Choice Members pdf format of 3q06Dist_choice.pdf
Medicare Advantage pdf format of 4q06Dist_choice.pdf
Other Medicare Members pdf format of 1q06Dist_medicare.pdf
Other Medicare Members pdf format of 2q06Dist_medicare.pdf
Other Medicare Members pdf format of 3q06Dist_medicare.pdf
Other Medicare Members pdf format of 4q06Dist_medicare.pdf
Medicaid Members pdf format of 1q06Dist_medicaid.pdf
Medicaid Members pdf format of 2q06Dist_medicaid.pdf
Medicaid Members pdf format of 3q06Dist_medicaid.pdf
Medicaid Members pdf format of 4q06Dist_medicaid.pdf
Individual Members pdf format of 1q06Dist_individual.pdf
Individual Members pdf format of 2q06Dist_individual.pdf
Individual Members pdf format of 3q06Dist_individual.pdf
Individual Members pdf format of 4q06Dist_individual.pdf
Other Members pdf format of 1q06Dist_other.pdf
Other Members pdf format of 2q06Dist_other.pdf
Other Members pdf format of 3q06Dist_other.pdf
Other Members pdf format of 4q06Dist_other.pdf

A Health Maintenance Organization ("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:
  1. 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.
  1. 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.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. 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).
  5. 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 2.0" 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. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this 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.