Massachusetts Membership in
Guaranteed Issue Nongroup Health Insurance Plans 1
as of December 31, 2004

Summary of guaranteed issue nongroup membership:
Total Membership Comparison 2003 to 2004 pdf format of TotalsJanDec_04.pdf
pdf format of                             Summary_county_04.pdf
Plan Type Comparison 2003 to 2004 by carier pdf format of Summary_carrier_04.pdf
pdf format of                             AgeSum_04.pdf

Guaranteed issue nongroup membership by plan by county:
Total Membership pdf format of TotalMemb_04.pdf
pdf format of                             TotalSub_04.pdf
Total Dependents pdf format of TotalDep_04.pdf
pdf format of                             type_hmo_04.pdf
Preferred Provider Plan Members pdf format of type_prprv_04.pdf
pdf format of                             type_med_04.pdf
Summary of Nongroup Members by Plan & County of Residence pdf format of Sum_04.pdf

Guaranteed issue nongroup membership by age by county:
Total Single and All Other Subscribers and Dependents pdf format of AgeTotal_04.pdf
pdf format of                             AgeTotalS_04.pdf
HMO Plan Members Single and All Other Subscribers and Dependents pdf format of age_HMO_04.pdf
pdf format of                             age_prefprov_04.pdf
Medical Plan Members Single and All Other Subscribers and Dependents pdf format of age_med_04.pdf

Introduction
The Division of Insurance ("Division") requested that all nongroup health insurance carriers submit a detailed report by February 2005 regarding the characteristics of their guarantee issue nongroup membership as of December 31, 2004.

What Are Guaranteed Issue Health Plans?
According to M.G.L. c. 176M, any carrier who is offering health coverage to eligible individuals in Massachusetts after October 1, 1997 may only offer guaranteed issue health plans which must be offered to all eligible persons without medical underwriting. Rates charged to eligible persons may only vary according to the specific rating factors allowed by M.G.L. c. 176M.

Guaranteed issued health plans must include a 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).

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

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.

Beginning November 1, 2001, carriers were permitted to offer alternate plans in addition to standard guaranteed issue plans. Currently, Harvard Pilgrim Health Care, Inc. and Blue Cross and Blue Shield of Massachusetts, Inc. are the only carriers offering such plans, accounting for 8,119 members.

Are There Any Other Options Available?
According to changes to the Nongroup Health Insurance Law enacted under Chapter 140 of the Acts of 2000, beginning November 1, 2001, carriers were allowed to offer one plan in addition to the standard plan. The alternate plan must include all the same core benefits as the standard plan, but may have higher copayments or deductibles and may exclude prescription drug coverage.

Who Is Eligible for Nongroup Guaranteed Issue Health Plans?
Prior to the recent changes in the law, persons could purchase a plan during the annual open enrollment period, which most recently took take place between September 1, 2001 and October 31, 2001, only if (1) they lived in Massachusetts; (2) did not have access to group health coverage through a workplace or a spouse's workplace; (3) were not eligible for continuation of group health coverage under COBRA or other continuation of coverage laws; and (4) were not enrolled in a government-sponsored plan.

As of November 1, 2001, subscribers and their dependents are eligible for this coverage if:
  • they are a Massachusetts resident; AND
  • they are not enrolled in Medicare or Medicaid (MassHealth)
It should be noted that laws regarding self-employed persons changed on November 1, 2001. Prior to November 1, a person could not enroll in a nongroup guaranteed issue plan if he or she were self-employed. Beginning November 1, 2001, self-employed persons may 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 guarantee issue 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 Plan.

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 guarantee 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 guarantee issue Nongroup coverage and is not the Subscriber or Contractholder of record and was specially named as a dependent in the application for coverage. 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, 2004.


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

All Other - Contract including subscriber, as well as dependents, including two-person 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 only from guaranteed issue health plans subject to M.G.L. c. 176M that are issued to all eligible persons. See separate report for membership in plans only available on a group conversion basis.

2 Excludes members in guaranteed issue health plans available only on a group conversion basis. See separate report for membership in guaranteed issue health plans only available on a group conversion basis.