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services, out-of-area services, and miscellaneous services such
as ambulance and pharmacy services.
To participate in petitioner’s IHC Care 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
and select the benefit package of his or her choice. Although
petitioner did not deny membership to enrollees with preexisting
medical conditions, petitioner denied full coverage for certain
preexisting conditions during the first 12 months of membership.
Petitioner did not own or operate any medical facilities,
nor did it directly employ any physicians or other health care
professionals. Petitioner fulfilled its obligation to arrange
for its IHC Care enrollees to receive physician services by
contracting with a panel of 1,165 primary care physicians and
specialist physicians to provide such services. Approximately 83
percent of these physicians were independent physicians while the
remaining 17 percent of the physician panel was composed of
physicians employed by Health Services. Petitioner required all
such physicians to have staff privileges at one of Health
Services’ hospitals.
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Last modified: May 25, 2011