- 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