- 16 -
Petitioner entered into some form of written agreement with
all enrollees specifying the premium charge and the medical
services to which the enrollee would be entitled. Petitioner
entered into master group contracts with all employers offering
its health plans. Thereafter, during annual open enrollment
periods, employees were permitted to enroll in the health plan
and select the benefit package of his or her choice.
Although petitioner did not limit its enrollment based upon
pre-existing medical conditions, certain plans excluded some pre-
existing conditions from full coverage during the first 12 months
of membership.
Petitioner applied an adjusted community rating methodology
to determine premiums for individual and small employer group
enrollees, adjusting its rates for risk factors such as age and
gender.5 Petitioner relied upon past claims experience to
determine premiums for large employer group enrollees.
B. Physician Services
Petitioner did not employ a significant number of
physicians.6 Petitioner fulfilled its obligation to arrange for
its enrollees to receive physician services by contracting with a
5 See 42 C.F.R. sec. 417.104(b) (1995), which sets forth the
requirements for acceptable community rating systems for
federally qualified HMOs.
6 Petitioner never employed more than five physicians at a
time, and these physicians were hired for the limited purpose of
conducting health fairs for enrollees.
Page: Previous 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 NextLast modified: May 25, 2011