Health Maintenance Organization
Year-End Supplemental Utilization Report
January 1, 2009 - December 31, 2009


Utilization by HMO:

Average Membership by Age Cohort pdf format of Supp_Util_Dist_YE09_Avg_Age.pdf
Inpatient Non-Behavioral Health Utilization pdf format of Supp_Util_Dist_YE09_InpNBH.pdf
Inpatient Behavioral Health Utilization pdf format of Supp_Util_Dist_YE09_InpBH.pdf
Inpatient Behavioral Health Utilization by Age Cohort pdf format of Supp_Util_Dist_YE09_InpBH_Age.pdf
Outpatient Non-Behavioral Health Utilization pdf format of Supp_Util_Dist_YE09_OpNBH.pdf
Outpatient Behavioral Health Utilization pdf format of Supp_Util_Dist_YE09_OpBH.pdf
Outpatient Behavioral Health Utilization by Age Cohort pdf format of Supp_Util_Dist_YE09_OpBH_Age.pdf
 

Introduction
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 or its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the Health Maintenance Organization's Evidence of Coverage.
According to the provisions of 211 CMR 43.05(2), each HMO shall file quarterly reports with the Division within 45 days of the close of each calendar quarter in the format specified by the National Association of Insurance Commissioners ("NAIC") or as otherwise specified by the Commissioner. Beginning in 2004, separate from the quarterly NAIC reports, HMOs will submit semi-annually to the Division a Supplemental Utilization Report providing detail regarding utilization statistics. The Division has requested that these reports only include utilization for Massachusetts residents in which the risk of financial loss has been transferred to the HMO; that is, it does not include any so-called "self-insured" business.
This report includes utilization for the entire HMO, whether provided or arranged by the HMO or any delegated entity or contracting network for all paid claims incurred during the reporting period, January 1, 2009 - December 31, 2009, with a paid through date of March 31, 2009. For the purpose of this report, "paid claims" mean any claim in which the HMO has made payment to the provider of service.

Utilization Statistics
Inpatient utilization statistics included in the report are as follows:
Total Discharges - the total number of formal releases of a patient from a facility for any reason, including death, that occurred between January 1, 2009 and December 31, 2009.
Annualized Discharges per 1,000 Members - the number of total discharges that occurred between January 1, 2009 and December 31, 2009 per 1,000 members annualized to reflect a 12-month equivalent.
Total Discharge Days - the total number of inpatient days associated with the total number of discharges that occurred between January 1, 2009 and December 31, 2009. All associated paid claims are counted, even if those days occurred prior to the beginning of the reporting period.
Annualized Discharge Days per 1,000 Members - the number of total discharge days that occurred between January 1, 2009 and December 31, 2009 per 1,000 members annualized to reflect a 12-month equivalent.
Average Length of Stay - total discharge days that occurred between January 1, 2009 and December 31, 2009 divided by total discharges that occurred between January 1, 2009 and December 31, 2009.
Outpatient utilization statistics included in the report are as follows:
Total Physician Encounters - the total number of face-to-face visits with a Medical Doctor or Doctor of Osteopathy that occurred between January 1, 2009 and December 31, 2009.
Annualized Physician Encounters per 1,000 Members - the number of total physician encounters that occurred between January 1, 2009 and December 31, 2009 per 1,000 members annualized to reflect a 12-month equivalent.
Total Non-Physician Encounters -
Non-Behavioral Health - the total number of face-to-face visits with a provider providing non-behavioral health services who is not a Medical Doctor, Doctor of Osteopathy, registered nurse, nurse aide, x-ray technician, lab assistant, pharmacist or medical supply vendor.
Behavioral Health - the total number of face-to-face visits with the following licensed or otherwise certified health professionals who provide behavioral health services: psychologists; psychotherapists; independent clinical social workers; mental health counselors; nurse mental health clinical specialists; alcohol and drug counselors; marriage and family therapists; advanced practice registered nurses; registered nurse clinical specialists; nurse practitioners; and psychiatric clinical nurse specialists.
Annualized Non-Physician Encounters per 1,000 Members - the number of total non-physician encounters that occurred between January 1, 2009 and December 31, 2009 per 1,000 members annualized to reflect a 12-month equivalent.
Total Encounters - the total number of face-to-face visits with a physician or non-physician that occurred between January 1, 2009 and December 31, 2009.
Annualized Encounters per 1,000 Members - the number of total physician and non-physician encounters that occurred between January 1, 2009 and December 31, 2009 per 1,000 members annualized to reflect a 12-month equivalent.
Inpatient Non-Behavioral Health Utilization
Inpatient non-behavioral health utilization statistics are categorized as follows:
Acute Care - non-behavioral health care in a hospital licensed as an acute care facility by the state in which the facility is located.
Maternity - as defined in the most resent version of the Health Plan Employer and Data Information Set ("HEDIS®") 1 technical specifications.
Non-Acute Care - non-behavioral health care in an inpatient facility or ward of a facility licensed by the state in which the facility is located but not as an acute facility. This includes, but is not limited to, the following: skilled nursing home; long-term care; intermediate care; rehabilitation; and hospice.
Outpatient Non-Behavioral Health Utilization
Outpatient non-behavioral health utilization statistics are categorized as follows:
Office Visits - non-behavioral health care encounters that are not emergency room or ambulatory surgical procedures (even if performed in the physician's office).
Ambulatory Surgery - as defined in the most resent version of HEDIS® technical specifications.
Observation Day - as defined in the most resent version of HEDIS® technical specifications.
Emergency Room - as defined in the most resent version of HEDIS® technical specifications.
Behavioral Health Utilization
Both inpatient and outpatient behavioral health utilization statistics are categorized as follows:
Major Depression - Primary ICD-9 diagnosis codes between 296.2 and 296.36.
Attention Deficit Hyperactivity Disorder - Primary ICD-9 diagnosis codes between 314 and 314.9.
Eating Disorders - Primary diagnosis code 307.1 or between 307.5 and 307.59.
Chemical Dependency - Primary ICD-9 diagnosis codes between 291 and 292.9 or between 303 and 305.93; OR primary ICD-9 diagnosis codes between 960 and 979 with secondary ICD-9 diagnosis codes between 291 and 292.9 or between 303 and 305.93.
Other Mental Health - Primary ICD-9 diagnosis codes between 290 and 316 excluding ICD-9 diagnosis codes between 296.2 and 296.36; between 314 and 314.9; 307.1; between 307.5 and 307.59; between 291 and 292.9; and between 303 and 305.93.

1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).