By the Division of Insurance
An insured preferred provider health plan is health coverage offering the insured a financial incentive to receive care from the plan’s network of preferred providers. The insurer offering the plan contracts with groups of preferred providers to furnish specified health care services including, but not limited to, hospital, medical, surgical, dental, vision or pharmaceutical services or products.
Insured preferred provider plans may be offered by: (1) a company licensed by the Commonwealth of Massachusetts to provide accident and sickness insurance pursuant to M.G.L. c. 175 (commercial insurer); (2) a Fraternal Benefit Society pursuant to M.G.L. c. 176; (3) a Non-profit Hospital and Medical Service Corporation licensed pursuant to M.G.L. c. 176A and 176B (Blue Cross and Blue Shield of Massachusetts, Inc.); (4) a Dental Service Corporation licensed pursuant to M.G.L. c. 176E (Dental Service of Massachusetts, Inc.); (5) an Optometric Service Corporation licensed pursuant to M.G.L. c. 176F (Vision Service Plan); or (6) a Health Maintenance Organization (“HMO”) licensed pursuant to M.G.L c. 176G. The Division of Insurance (“Division”) will approve an insured preferred provider plan if it satisfies the specific standards of M.G.L. c. 176I and 211 CMR 51.00 (the statute and regulation governing insured preferred provider health plans). Please note that carriers offering such managed care plans must also be accredited by the Division’s Bureau of Managed Care according the provisions of M.G.L. c. 176O, 105 CMR 128.000, and 211 CMR 52.00.
According to the provisions of 211 CMR 51.06(2), each carrier offering an insured preferred provider health plan must file an annual report for each insured preferred provider product that it operates in Massachusetts within 120 days of the end of the carrier’s fiscal year. The Division requested that insurers submit raw data on actual membership, so that the Division could calculate statistics and develop summary information. This report summarizes each carrier’s membership as of December 31, 2015.
The membership report is based on the 2015 Insured Preferred Provider Plan Membership and Utilization Statistic Reports currently on file with the Division by carriers marketing these plans in Massachusetts’ group and individual markets, as well as companies who are no longer selling new coverage, but are continuing to renew existing policies or contracts. The membership data reflects members who live in Massachusetts and are in a plan approved in Massachusetts. (They do not include members living in other states nor do they include members in plans issued to groups outside Massachusetts.) For the purpose of this report, membership includes all subscribers and covered dependents of a subscriber (including divorced spouses covered newborns covered under the carrier’s insured preferred provider plan on December 31, 2015) for whom the carrier has accepted the risk of financing necessary health services. Membership was reported by county 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). Please note that there were no preferred provider organizations which, at the end of 2015, had membership in Mental Health and Substance Abuse plans and Prescription Drug Expense plans.
Types of Approved Insured Preferred Provider Plans
- Mental Health and Substance Abuse
- Prescription Drug Expense