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high quality care to members of the community,
including elderly and disadvantaged persons, and it may
conduct research and educational demonstration projects
with various health care delivery systems.
Petitioner was licensed to operate an HMO in the State of
Utah and was subject to regulation by the Utah Insurance
Commissioner. Petitioner used the same network of health care
providers used by Health Plans.
2. IHC Group, Inc.
In July 1991, Health Plans organized Group as a nonprofit
affiliate for the purpose of establishing a federally qualified
medical group model HMO.5 Health Plans was Group’s sole
corporate member.
Group was licensed to operate an HMO in the State of Utah
and was subject to regulation by the Utah Insurance Commissioner.
IHC had effective control of Health Plans, petitioner, and
Group by virtue of its authority (direct and indirect) to elect
their boards of trustees. Health Plans, petitioner, and Group
shared the same officers and trustees.
II. Petitioner’s Operations
Health Plans structured its health plans in conjunction with
5 Group was considered a closed panel, medical group model HMO
because Group contracted for physician services with physician
medical groups and required its enrollees to agree to coordinate
all of their medical care through a primary care physician (PCP)
or so-called gatekeeper. In cases in which the PCP determined
that an enrollee should be seen by a medical specialist, the PCP
generally was expected to refer the enrollee to a specialist
within the PCP’s medical group.
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Last modified: May 25, 2011