Health Maintenance Organization
Year-End Supplemental Utilization Report
January 1, 2011 - December 31, 2011
Utilization by HMO:
Average Membership by Age Cohort
Inpatient Non-Behavioral Health Utilization
Outpatient Non-Behavioral Health Utilization
Inpatient Behavioral Health Utilization
Inpatient Behavioral Health Utilization by Age Cohort
Intermediate Care Behavioral Health Utilization
Outpatient Behavioral Health Utilization
Outpatient Behavioral Health Utilization by Age Cohort
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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. |
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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. |
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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, 2011 - December 31, 2011, with a paid through date of March 31, 2012. For the purpose of this report, "paid claims" mean any claim in which the HMO has made payment to the provider of service. |
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Inpatient utilization statistics included in the report are as follows:
Intermediate care utilization statistics included in the report are as follows: |
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Total Discharges - the total number of formal releases of a patient from a facility for any reason, including death that occurred between January 1, 2011 and December 31, 2011. |
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Annualized Discharges per 1,000 Members - the number of total discharges that occurred between January 1, 2011 and December 31, 2011 per 1,000 members annualized to reflect a 12-month equivalent. |
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Total Discharge Days - the total number of intermediate care days associated with the total number of discharges that occurred between January 1, 2011 and December 31, 2011. All associated paid claims are counted, even if those days occurred prior to the beginning of the reporting period. |
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Annualized Discharge Days per 1,000 Members - the number of total discharge days that occurred between January 1, 2011 and December 31, 2011 per 1,000 members annualized to reflect a 12-month equivalent. |
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Average Length of Stay - total discharge days that occurred between January 1, 2011 and December 31, 2011 divided by total discharges that occurred between January 1, 2011 and December 31, 2011. |
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Total Encounters - the total number of face-to-face visits with a physician or non-physician that occurred between January 1, 2011 and December 31, 2011. |
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Outpatient utilization statistics included in the report are as follows:
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Inpatient Non-Behavioral Health Utilization |
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Inpatient non-behavioral health utilization statistics are categorized as follows:
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Outpatient Non-Behavioral Health Utilization |
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Outpatient non-behavioral health utilization statistics are categorized as follows:
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Behavioral Health Utilization |
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Both inpatient, intermediate care, and outpatient behavioral health utilization statistics are categorized as follows:
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