Massachusetts Membership in Guaranteed Issue Nongroup Health Insurance Plans Issued Only on a Group Conversion Basis 1 as of December 31, 2003


Summary of guaranteed issue nongroup group conversion membership:
Total Membership Comparison 2002 to 2003 pdf format of TotalsJanDecConv_03.pdf
pdf format of                             SummaryConv_company_03.pdf
Plan Type Comparison by carrier 2002 to 2003 pdf format of SummaryConv_carrier_03.pdf
pdf format of                             AgeSumConv_03.pdf

Guaranteed issue nongroup group conversion membership by plan by county:
Total Membership pdf format of TotalConvMemb_03.pdf
pdf format of                             TotalConvSub_03.pdf
Total Dependents pdf format of TotalConvDep_03.pdf
pdf format of                             type_hmoConv_03.pdf
Preferred Provider Plan Members pdf format of type_prprvConv_03.pdf
pdf format of                             type_medConv_03.pdf
Summary of Nongroup Members by Plan and County of Residence pdf format of SumConv_03.pdf

Guaranteed issue nongroup group conversion membership by age by county:
Total Single and All Other Subscribers and Dependents pdf format of AgeTotalConv_03.pdf
pdf format of                             AgeTotalConvS_03.pdf
HMO Plan Members Single and All Other Subscribers and Dependents pdf format of age_HMOConv_03.pdf
pdf format of                             age_prefprovConv_03.pdf
Medical Plan Members Single and All Other Subscribers and Dependents pdf format of age_medConv_03.pdf

Introduction
The Division of Insurance ("Division") requested that all nongroup health insurance carriers submit a detailed report by February 14, 2004 regarding the characteristics of their guaranteed issue nongroup group conversion membership as of December 31, 2003.

What Are Group Conversion Guaranteed Issue Health Plans?
A group conversion health plan is a nongroup health plan offered, sold, issued, delivered, made effective or renewed by a group health carrier to a former employee or member or his/her dependents, including a spouse of a former employee or member who is no longer eligible for group health coverage. According to M.G.L. c. 176M any carrier offering health coverage to eligible individuals, including group conversion plans, in Massachusetts after October 1, 1997 may only offer the standard guaranteed issue health plans which must be offered without medical underwriting. Rates charged to eligible persons may only vary according to the specific rating factors allowed by M.G.L. c. 176M. According to M.G.L. c. 176M, § 2(a), a carrier offering a guaranteed issue health plan only on a group conversion basis is not required to offer to other eligible individuals.

Group conversion guaranteed issued health plans must include a standard set of benefits including emergency, hospital and physician services, preventive care, and prescription drugs administered on an outpatient basis and cost sharing levels (deductibles and coinsurance) that meet the minimum standards as established by the Nongroup Health Insurance Advisory Board. If they choose, carriers may offer an enhanced plan with more than the standard benefits, but they must offer at least the standard benefits as designed by the Nongroup Health Insurance Advisory Board.

What Types of Guaranteed Issue Health Plans Are Offered?
There are three types of standardized plans offered in the market:

Medical plans, without any restrictions on choices of medical providers. This is a traditional health plan in which covered persons may go to any licensed hospital, doctor, or provider for your treatment. In the standard plan, there is an annual deductible ($700 per member/$1,400 per family) and coinsurance of 20% for most covered services.

Preferred provider plans, with incentives to go to preferred providers. In these plans, covered persons may go to any licensed hospital, doctor or provider, but will pay a smaller share of the cost if you go to providers on the preferred list. In the standard plan, covered persons will be required to pay an annual deductible ($250 per member/$500 per family) and 10% of covered services from preferred providers and 30% from all other providers.

Managed care plans, offered by HMOs with closed networks of providers. Except in cases of emergency and specific situations, covered persons must use providers within the HMO network in order to receive benefits. In the standard plan, there are copayments ranging from $15 for each office visit to $500 for a hospital stay.

Eligibility
Beginning November 1, 2001, a person is eligible for this coverage if:
  • He or she is a Massachusetts resident; AND
  • He or she is not enrolled in Medicare or Medicaid (MassHealth)
Please note that laws regarding self-employed persons changed on November 1, 2001. Prior to November 1, Massachusetts residents could not enroll in a nongroup guaranteed issue plan if they were self-employed. Beginning November 1, 2001, self-employed persons became eligible to now enroll in either a small group plan or a nongroup guaranteed issue plan.

The following sections of this report describe what is included in the categorical headings used in the accompanying membership charts.

General
Company - Name of the licensed carrier offering the group conversion guaranteed issue nongroup product. This is not the name of a provider network or third party administrator but rather the licensed carrier that bears the financial risk.

Type of Plan - Managed Care Plan, Preferred Provider Plan, Medical Plan or Alternative.

County - County in which the subscriber resides.


Membership 2
Member - Covered person including all subscribers and dependents.

Subscriber - "Contractholder" who is an eligible individual who has enrolled alone, or with his or her dependents for whom the carrier has accepted the risk of financing necessary health services via a guaranteed issue nongroup plan. A Subscriber should be reported by county according to the zip code of the Subscriber's primary residence listed on the application for coverage.

Dependent - Eligible individual who is enrolled for group conversion guaranteed issue nongroup coverage and is not the Subscriber or Contractholder of record and was specially named as a dependent in the application for coverage. If possible, a Dependent should be reported by county according to the zip code of the Dependent's primary residence listed on the application for coverage.

Age - Age of the member as of December 31, 2003.


Rate Basis Type
Single - Contract including the subscriber without any dependents.

All Other - Contract including subscriber, as well as dependents, including two-person, adult with children and family contracts.

Average Family Size - Average number of members enrolled in All Other contracts. The figure is calculated by dividing the members in All Other contracts by the subscribers in All Other contracts.


1 Represents membership in guaranteed issue health plans subject to M.G.L. c. 176M that are issued only on a group conversion basis to eligible persons converting from group health products. See separate report for membership in guaranteed issue health plans available to all eligible persons.

2 Excludes members from guaranteed issue health plans subject to M.G.L. c. 176M that are issued to all eligible persons in guaranteed issue health plans. See separate report for membership in guaranteed issue health plans available to all eligible persons.