HMO Membership Reports

Membership Reports by HMO by County According to 211 CMR 43.05(2), each health maintenance organization (HMO) shall file quarterly reports with the Division 45 days after the close of each calendar quarter.

Table of Contents

2022 HMO Membership Reports

1st Quarter        
Membership Trends      
Total Members      
Group Members      
Medicare Advantage Members      
Other Medicare Members      
Medicaid Members      
Individual Members      
Other Members      

2021 HMO Membership Reports

 

Executive Summary 

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 6,388 members from the ends of the 3rd quarter of 2021 to end the end of the 4th quarter of 2021: a percentage change of -0.33%. During this time period, membership in group closed network plans decreased by 9,502 members; membership in Medicare Advantage closed network plans decreased by 12 members; membership in other Medicare closed network plans decreased by 41 members; membership in Medicaid closed network plans increased by 14,383 members; membership in individual closed network plans decreased by 11,216 members; and membership in other closed network plans remained at zero. Tufts Health Public Plans, Inc. had the largest shared of insured members in closed network plans at the end of the 4th quarter of 2021.

HMO membership in preferred network plans increased by 2,169 members from the end of the 3rd quarter of 2021 to the end of the 4th quarter of 2021: a percentage change of 0.97%. During this time period, membership in group preferred network plans increased by 1,603 members; membership in Medicare Advantage preferred network plans increased by 610 members; membership in individual closed network plans decreased by 44 members; and membership in other Medicare, Medicaid, and other preferred network plans remained at zero. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the largest share of insured members in preferred network plans at the end of the 4th quarter of 2021.

 

2020 HMO Membership Reports

By County

 

 

Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans increased by 19,192 members from the end of the 2rd quarter of 2020 to the end of the 3th quarter of 2020; a percentage change of 0.98%. During this time period, membership in group closed network plans decreased by 20,692 members; membership in Medicare Advantage closed network plans increased by 1,108 members; membership in other Medicare closed network plans increased by 7 members; membership in closed network Medicaid plans increased by 36,429 members; membership in closed network individual plans increased by 2,340 members; and membership in other closed network plans remained at zero. Tufts Health Public Plans, Inc. had the largest share of insured members in closed network plans at the end of the 3rd quarter of 2020.

Introduction

 

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

 

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

 

 

Membership is identified by the following categories:

 

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

 

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.

 

Federal - employees of the federal government.

 

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

 

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

 

  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]

 

  1. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.

 

  1. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.

 

  1. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).

 

  1. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

 

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

 

Starting with the first quarter of 2017, carriers are no longer submitting data for this report directly to the Division.  Instead, beginning with the first quarter 2017, data shown in this report was produced by the Center for Health Information and Analysis using data submissions by the HMOs to the All-Payer Claims Database.  As a result, comparing membership for certain quarters may not be appropriate, as the data is taken from separate sources.

2019 HMO Membership Reports

By County

 

 

Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 21,367 members from the end of the 3rd quarter of 2019 to the end of the 4th quarter of 2019; a percentage change of -1.1%. During this time period, membership in group closed network plans decreased by 8,761 members; membership in Medicare Advantage closed network plans increased by 233 members; membership in other Medicare closed network plans decreased by 47 members; membership in closed network Medicaid plans decreased by 10,622 members; membership in closed network individual plans decreased by 2,170 members; and membership in other closed network plans remained at zero. Tufts Health Public Plans, Inc. had the majority of insured members in closed network plans at the end of the 4th quarter of 2019.

 

Introduction

 

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

 

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

 

 

Membership is identified by the following categories:

 

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

 

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.

 

Federal - employees of the federal government.

 

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

 

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

 

  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]

 

  1. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.

 

  1. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.

 

  1. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).

 

  1. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

 

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

 

Starting with the first quarter of 2017, carriers are no longer submitting data for this report directly to the Division.  Instead, beginning with the first quarter 2017, data shown in this report was produced by the Center for Health Information and Analysis using data submissions by the HMOs to the All-Payer Claims Database.  As a result, comparing membership for certain quarters may not be appropriate, as the data is taken from separate sources.

 

2018 HMO Membership Reports

By County

 

 

Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 14,186 members from the end of the 3rd quarter of 2018 to the end of the 4th quarter of 2018; a percentage decrease of 0.7%. During this time period, membership in group closed network plans decreased by 7,553 members; membership in Medicare Advantage closed network plans increased by 126 members; membership in other Medicare closed network plans increased by 102 members; membership in closed network Medicaid plans decreased by 5,163 members; membership in closed network individual plans decreased by 1,698 members; and membership in other closed network plans remained at zero. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of insured members in closed network plans at the end of the 4th quarter of 2018.

 

Introduction

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

 

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

 

 

 

Membership is identified by the following categories:

 

1.      Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

 

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.

 

Federal - employees of the federal government.

 

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

 

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

 

2.      Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]

 

3.      Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.

 

4.      Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.

 

5.      Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).

 

6.      Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

 

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

 

Starting with the first quarter of 2017, carriers are no longer submitting data for this report directly to the Division.  Instead, beginning with the first quarter 2017, data shown in this report was produced by the Center for Health Information and Analysis using data submissions by the HMOs to the All-Payer Claims Database.  As a result, comparing membership for certain quarters may not be appropriate, as the data is taken from separate sources.

2017 HMO Membership Reports

By County

 

Executive Summary

 

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 2,232 members from the end of the 3rd quarter of 2017 to the end of the 4th quarter of 2017; a percentage decrease of 1.12%. During this time period, membership in group closed network plans decreased by 5,609 members; membership in Medicare Advantage closed network plans increased by 441 members; membership in other Medicare closed network plans increased by 586 members; membership in closed network Medicaid plans decreased by 15,307 members; membership in closed network individual plans decreased by 6,396 members; and membership in other closed network plans increased from 1 to 2. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of insured members in closed network plans at the end of the 4th quarter of 2017.

 

Introduction

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

 

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

 

Membership is identified by the following categories:

 

1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

 

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.

Federal - employees of the federal government.

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

2. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]

3. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.

4. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.

5. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).

6. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

 

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

 

Starting with the first quarter of 2017, carriers are no longer submitting data for this report directly to the Division. Instead, the first quarter 2017 data shown in this report was produced by the Center for Health Information and Analysis using data submissions by the HMOs to the All-Payer Claims Database. As a result, comparing membership from the fourth quarter of 2016 to the first quarter of 2017 may not be appropriate, as the data is taken from separate sources.

2016 HMO Membership Reports

By county:


 

Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 31,100 members from the end of the 3rd quarter of 2016 to the end of the 4th quarter of 2016; a percentage decrease of 1.38%. During this time period, membership in group closed network plans decreased by 8,262 members; membership in Medicare Advantage closed network plans increased by 233 members; membership in other Medicare closed network plans decreased by 154 members; membership in closed network Medicaid plans decreased by 27,413 members; membership in closed network individual plans increased by 4,496 members; and membership in other closed network plans remained at zero. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of insured members in closed network plans at the end of the 4th quarter of 2016.

Introduction

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.

Federal - employees of the federal government.

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

  1. Medicare Advantage - members enrolled in a Medicare Advantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes closed guaranteed issue health plan members, and closed non group health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2015 HMO Membership Reports

By county:
 


Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 1,427 members from the end of the 3rd quarter of 2015 to the end of the  4th quarter of 2015; a percentage decrease of 0.1%. During this time period, membership in group closed network plans decreased by 7,727 members; membership in Medicare Advantage closed network plans decreased by 309 members; membership in other Medicare closed network plans increased by 109 members; membership in closed network Medicaid plans increased by 2,380 members; membership in closed network individual plans increased by 4,120 members; and membership in other closed network plans remained at zero.   Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2015, with 20.4% of the market.

Introduction

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission

Federal - employees of the federal government.

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2014 HMO Membership Reports

By county:


Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans decreased by 2,056 members from the end of the 3rd quarter of 2014 to the end of the 4th quarter of 2014; a percentage decrease of 0.09%. During this time period, membership in group closed network plans decreased by 1,588 members; membership in Medicare Advantage closed network plans decreased by 211 members; membership in other Medicare closed network plans increased by 230 members; membership in closed network Medicaid plans increased by 7,013 members; membership in closed network individual plans decreased by 7,119 members; and membership in other closed network plans decreased by 381. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2014, with 22.27% of the market.

Introduction

An 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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.

Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission

Federal - employees of the federal government.

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.

  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.1" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2013 HMO Membership Reports

By county:
 


 Membership


Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans increased by 13,530 members from the end of the 3rd quarter of 2013 to the end of the 4th quarter of 2013, a percentage increase of .6% . During this time period, membership in group closed network plans decreased by 1,400 members, as well as an increase of 9,094 members in Medicaid closed network plans, while there were increases of 792 members in Medicare Advantage closed network plans and 4,317 members in individual closed network plans. The membership in other Medicare closed network plans increased by 262 members. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2013, with 23.8% of the market.

Introduction

An ("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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.

According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.
Membership is identified by the following categories:

 

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:

GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.

Federal - employees of the federal government.

COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.

Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to cover eligible members of the entity.

Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.

  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  1. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  1. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  1. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  1. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2012 HMO Membership Reports

By County


 Membership


Executive Summary

 

Total Health Maintenance Organization (“HMO”) membership in closed network plans increased by 7,435 members from the end of the 4th quarter of 2011 to the end of the 4th quarter of 2012, a percentage increase of .35%. During this time period, membership in group closed network plans decreased by 59,583 members, while there were increases of 3,045 members in Medicare Advantage closed network plans, 27,691 members in Medicaid closed network plans, and 24,777 members in individual closed network plans. The membership in other Medicare closed network plans decreased by 893 members. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2012, with 23.69% of the market.

Introduction

An ("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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.
According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.
Membership is identified by the following categories:
  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of
the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to
cover eligible members of the entity.
Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  1. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  1. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  1. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  1. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.
The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2011 HMO Membership Reports

By county:

Executive Summary

Total Health Maintenance Organization (“HMO”) membership in closed network plans increased by 109,792 members from the end of the 3rd quarter of 2010 to the end of the 3rd quarter of 2011, a percentage increase of 5.5%.  During this time period, membership in group closed network plans decreased by 51,349 members, membership in Medicare Advantage closed network plans decreased by 20,943, while there were increases of 146,534 members in Medicaid closed network plans, and 35,585 members in individual closed network plans.  The membership in other Medicare closed network plans decreased by 31 members.  Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 3rd quarter of 2011, with 25.1% of the market.

IntroductionAn ("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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
 
Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of
the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to
cover eligible members of the entity.
 
Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

MembershipThe membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2010 HMO Membership Reports

By county: 

Executive Summary


Total Health Maintenance Organization ("HMO") membership in closed network plans decreased by 70,254 from the end of the 4th quarter of 2009 to the end of the 4th quarter of 2010, a percentage decrease of 3.35%. During this time period, membership in group closed network plans decreased by 109,526 members, membership in Medicare Advantage closed network plans decreased by 3,919 members, while there were increases of 35,890 members in Medicaid closed network plans, and 6,735 members in individual closed network plans. The membership in other Medicare closed network plans increased by 570 members. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2010, with 28.4% of the market.

IntroductionAn ("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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of
the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to
cover eligible members of the entity.
Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

MembershipThe membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 6.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2009 HMO Membership Reports

By County

Executive Summary


Total Health Maintenance Organization ("HMO") membership in closed network plans decreased by 29,985 from the end of the 4th quarter of 2008 to the end of the 4th quarter of 2009, a percentage decrease of 1.4%. During this time period, membership in group closed network plans decreased by 86,941 members, while there were increases of 3,902 members in Medicare Advantage closed network plans, 27,394 members in Medicaid closed network plans, and 25,411 members in individual closed network plans. The membership in other Medicare closed network plans stayed relatively flat during this time period. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2009, with 33.7% of the market.

Introduction

An ("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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.
According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.
Membership is identified by the following categories:
  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of
the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to
cover eligible members of the entity.
Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members (Commonwealth Care is a program coordinated by the Commonwealth Health Connector for individuals who meet specific income eligibility requirements),members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.
Membership
The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 5.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2008 HMO Membership Reports

By County

Executive Summary


Total Health Maintenance Organization ("HMO") membership in closed network plans increased by 163,955 members from the end of the 4th quarter of 2007 to the end of the 4th quarter of 2008, a percentage increased of 8.4%. During this time period, membership in group closed network plans decreased by 101,089 members, while there were increases of 3,799 members in Medicare Advantage closed network plans, 175,545 members in Medicaid closed network plans, and 85,708 members in individual closed network plans. The membership in other Medicare closed network plans stayed relatively flat during this time period. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. had the majority of members in closed network plans at the end of the 4th quarter of 2008, with 36.9% of the market.

IntroductionAn ("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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
 
Merged Market - members enrolled in those merged small group/individual products (pursuant to Chapter 58 of
the Acts of 2006) who belong to an entity (e.g., employer, association, or trust) paying premiums to the HMO to
cover eligible members of the entity.
 
Commonwealth Choice - members enrolled in the Commonwealth Choice contributory plan.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic includes those merged small group/individual product (pursuant to Chapter 58 of the Acts of 2006) members who enroll as individuals, and do not belong to a group. Statistic also includes Commonwealth Care members, members enrolled in the Commonwealth Choice non-contributory plan, closed guaranteed issue health plan members, and closed nongroup health plan members. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

MembershipThe membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 4.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2007 HMO Membership Reports

By County

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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.Membership is identified by the following categories:

  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.

MembershipThe membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 2.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2006 HMO Membership Reports

By County

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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.
According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.
Membership is identified by the following categories:
  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.
Membership
The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 2.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.

2005 HMO Membership Reports

By County

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 of its obligations to its members. The HMO contracts with specific groups of providers to furnish the specified health care services covered by the HMO's Evidence of Coverage.
According to the provisions of 211 CMR 43.05(2), HMOs must file quarterly reports with the Division within 45 days of the close of each calendar quarter. The Division has requested that these reports only include statistics of membership for which the risk of financial loss has been transferred to the HMO; that is, it does not include so-called "self-insured" business. This report summarizes the membership information included in each carrier's report.
Membership is identified by the following categories:
  1. Group - members enrolled with the HMO through an entity (e.g., employer, association or trust) paying premiums to the HMO to cover eligible members of the entity. This category includes the following types of group members:
GIC - employees of the Massachusetts state government enrolled through the Group Insurance Commission.
Federal - employees of the federal government.
COBRA - members who receive their health coverage from the HMO pursuant to continuation of coverage protections guaranteed by the Consolidated Omnibus Budget Reconciliation Act of 1985 and members who receive their health coverage pursuant to M.G.L. c. 176J, § 9 for groups with between 2 - 19 eligible employees.
  1. Medicare Advantage - members enrolled in a MedicareAdvantage contract with the Centers for Medicare and Medicaid Services ("CMS"). [Formerly known as Medicare+Choice, renamed by the Medicare Prescription Drug Improvement and Modernization Act of 2003.]
  2. Other Medicare - members enrolled in other Medicare plans, including, for example, so-called "Medicare Wrap-Around" policies.
  3. Medicaid - members with HMO health coverage in which reimbursement is provided pursuant to Title XIX of the Federal Social Security Act.
  4. Individual - members who do not belong to a group and who directly contract with the HMO for coverage. Statistic may include a subscriber's formerly dependent divorced spouse following subscriber's remarriage. Statistic does not include (a) individual conversion policy members (included in the Other category); (b) COBRA members (included in the Group category); or (c) self-employed small group members (included in the Group category).
  5. Other - members whose group coverage and COBRA coverage have expired and who have converted to an individual (conversion) policy.
Membership
The membership statistics reflect information filed by the organization ONLY and are based upon the Massachusetts Division of Insurance's "Guidelines for Reporting Membership and Utilization Statistics - Version 2.0" that instructs HMOs to exclude members for whom the HMO did not bear any financial risk. Membership is reported only for members residing in Massachusetts, based on the county of residence, 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); if the member's primary residence was outside Massachusetts, it is not included on the attached membership report. Beginning January 1, 2004, membership reflects those persons enrolled ONLY in closed network plans; so-called "dual certificate option" plan (POS) members and insured preferred provider plan members are not included in this report. For the purpose of this report, membership includes all subscribers or covered dependents of a subscriber (including divorced spouses and newborns covered under the carrier's HMO plan) for whom the carrier has accepted the risk of financing necessary health services.
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