- 10 -
and Care including marketing, sales, enrollment, customer
service, claims processing, underwriting and actuarial services,
provider relations and contracting, management information
systems, and general accounting services.
A. Petitioner’s SelectMed Health Plan
Petitioner operated a closed panel, medical group model HMO
offering a health plan known as SelectMed to employers with
more than 100 employees.5 In short, as petitioner did not itself
provide health care services, it arranged for its enrollees to
receive such services by contracting directly with physician
medical groups to provide health services to its enrollees.
Petitioner collected premiums from its enrollees and arranged for
them to receive comprehensive health care services, including
preventive care, outpatient services, inpatient hospital
services, emergency services, out-of-area services, and
miscellaneous services such as ambulance and pharmacy services.
To participate in petitioner’s SelectMed health plan, an
employer was required to enter into a master group contract.
Thereafter, during annual open enrollment periods, the employer’s
individual employees were permitted to enroll in the health plan
5 Health Plans also offered plans known as SelectMed and
SelectMed Plus. The principal differences between petitioner’s
SelectMed plan and the SelectMed plans offered by Health Plans
related to the methodology applied in determining premiums and
enrollees’ degree of access to primary care physicians. See IHC
Health Plans, Inc. v. Commissioner, T.C. Memo. 2001-246.
Page: Previous 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Next
Last modified: May 25, 2011