Summary of guaranteed issue non-group group conversion membership:
Total Membership Comparison 2005 to 2006 by county Plan Type Comparison 2005 to 2006 by age and county
|
|
|
Introduction |
| The Division of Insurance ("Division") requested that all nongroup health insurance carriers submit a detailed report by February 14, 2007 regarding the characteristics of their guaranteed issue nongroup group conversion membership as of December 31, 2006. |
What Are Group Conversion Guaranteed Issue Health Plans? |
| A group conversion health plan is a nongroup health plan offered, sold, issued, delivered, made effective or renewed by a group health carrier to a former employee or member or his/her dependents, including a spouse of a former employee or member who is no longer eligible for group health coverage. According to M.G.L. c. 176M any carrier offering health coverage to eligible individuals, including group conversion plans, in Massachusetts after October 1, 1997 may only offer the standard guaranteed issue health plans which must be offered without medical underwriting. Rates charged to eligible persons may only vary according to the specific rating factors allowed by M.G.L. c. 176M. According to M.G.L. c. 176M, § 2(a), a carrier offering a guaranteed issue health plan only on a group conversion basis is not required to offer to other eligible individuals. |
Group conversion guaranteed issued health plans must include a standard set of benefits including emergency, hospital and physician services, preventive care, and prescription drugs administered on an outpatient basis and cost sharing levels (deductibles and coinsurance) that meet the minimum standards as established by the Nongroup Health Insurance Advisory Board. If they choose, carriers may offer an enhanced plan with more than the standard benefits, but they must offer at least the standard benefits as designed by the Nongroup Health Insurance Advisory Board. |
What Types of Guaranteed Issue Health Plans Are Offered? |
| There are three types of standardized plans offered in the market: |
Medical plans, without any restrictions on choices of medical providers. This is a traditional health plan in which covered persons may go to any licensed hospital, doctor, or provider for your treatment. In the standard plan, there is an annual deductible ($700 per member/$1,400 per family) and coinsurance of 20% for most covered services. |
Preferred provider plans, with incentives to go to preferred providers. In these plans, covered persons may go to any licensed hospital, doctor or provider, but will pay a smaller share of the cost if you go to providers on the preferred list. In the standard plan, covered persons will be required to pay an annual deductible ($250 per member/$500 per family) and 10% of covered services from preferred providers and 30% from all other providers. |
Managed care plans, offered by HMOs with closed networks of providers. Except in cases of emergency and specific situations, covered persons must use providers within the HMO network in order to receive benefits. In the standard plan, there are copayments ranging from $15 for each office visit to $500 for a hospital stay. |
| Please note, in 2006 the Massachusetts Legislature passed Section 94 of Chapter 58 modifying M.G.L. c. 176M §3(d). The statute now states that effective July 1, 2007, a carrier shall no longer offer, sell, or deliver a guaranteed issue health plan to any person to whom it does not have such an obligation pursuant to an individual policy and will be considered a closed guaranteed issue plan. Closed guaranteed issue plans and closed health plan [individual health insurance plans that were in force prior to October 1, 1997] shall be subject to all the other requirements of the statute. Carriers are obligated to renew a closed guarantee issue health plans and closed plans. Carriers may discontinue a closed guarantee issue health plan or a closed plan when the number of subscribers in a closed guaranteed issue plan or a closed plan is less than 25 per cent of the plan's subscriber total as of December 31, 2004. |
Eligibility |
Beginning November 1, 2001, a person is eligible for this coverage if:
|
| Please note that laws regarding self-employed persons changed on November 1, 2001. Prior to November 1, Massachusetts residents could not enroll in a nongroup guaranteed issue plan if they were self-employed. Beginning November 1, 2001, self-employed persons became eligible to now enroll in either a small group plan or a nongroup guaranteed issue plan. |
The following sections of this report describe what is included in the categorical headings used in the accompanying membership charts. |
General |
| Company - Name of the licensed carrier offering the group conversion guaranteed issue nongroup product. This is not the name of a provider network or third party administrator but rather the licensed carrier that bears the financial risk. |
Type of Plan - Managed Care Plan, Preferred Provider Plan, Medical Plan or Alternative. |
County - County in which the subscriber resides. |
Membership 2 |
| Member - Covered person including all subscribers and dependents. |
Subscriber - "Contractholder" who is an eligible individual who has enrolled alone, or with his or her dependents for whom the carrier has accepted the risk of financing necessary health services via a guaranteed issue nongroup plan. A Subscriber should be reported by county according to the zip code of the Subscriber's primary residence listed on the application for coverage. |
Dependent - Eligible individual who is enrolled for group conversion guaranteed issue nongroup coverage and is not the Subscriber or Contractholder of record and was specially named as a dependent in the application for coverage. If possible, a Dependent should be reported by county according to the zip code of the Dependent's primary residence listed on the application for coverage. |
Age - Age of the member as of December 31, 2006. |
Rate Basis Type |
| Single - Contract including the subscriber without any dependents. |
All Other - Contract including subscriber, as well as dependents, including two-person, adult with children and family contracts. |
Average Family Size - Average number of members enrolled in All Other contracts. The figure is calculated by dividing the members in All Other contracts by the subscribers in All Other contracts. |
1 Represents membership in guaranteed issue health plans subject to M.G.L. c. 176M that are issued only on a group conversion basis to eligible persons converting from group health products. See separate report for membership in guaranteed issue health plans available to all eligible persons. 2 Excludes members from guaranteed issue health plans subject to M.G.L. c. 176M that are issued to all eligible persons in guaranteed issue health plans. See separate report for membership in guaranteed issue health plans available to all eligible persons. |
2006 Non-Group Guaranteed Issue Conversion Report