HMOs off 25 percent

HMO membership in Connecticut dropped by nearly a quarter in 2009, as businesses opted for indemnity plans carrying higher deductibles and other costs, in an attempt to limit premium hikes.

Indemnity plan membership jumped 13.1 percent, according to the Connecticut Insurance Department”™s annual report care on insurance carrier performance. The report includes managed-care plans offered by HMOs or traditional indemnity companies, which attempt to manage the cost and quality of health care by promoting early detection and preventive care under the supervision of a primary care physician who participates in the managed care plan”™s network.

CID releases the report each fall, coinciding with the open-enrollment periods during which the highest number of businesses and consumers consider changes to their health insurance coverage. In addition to customer counts, the report includes data on the number of health-care providers carriers use in each county; doctor performance under each plan in areas such as preventative screening; how often carriers deny claims for medical services; and how often those denials are reversed on appeal.

Aetna keeps HMO membership even
Aetna Inc. was the lone carrier in Connecticut to hold its HMO membership steady, while Anthem Blue Cross Blue Shield had the sharpest drop of HMO membership in the state at 37.2 percent, against a 24.5 percent decline for all six carriers offering HMO plans as of June 2009. The Wellpoint Inc. subsidiary also had a 3.2 percent falloff in its indemnity plans, against the 13.1 percent statewide gain.

At deadline, an Anthem spokeswoman had yet to reply to a request for comment.

Even as it completed the takeover of Health Net of the Northeast Inc.”™s business in Connecticut, UnitedHealth Group saw membership numbers ebb in both Health Net”™s HMO and indemnity plans.

Under the original parameters of the deal as disclosed in a press release, UnitedHealth was scheduled to pay Health Net additional consideration on a per-member basis as Health Net”™s Northeast commercial customers transitioned to UnitedHealth, up to $120 million in total.

UnitedHealth spokeswoman Anayo Afolabi was unable to say to what degree if any Health Net”™s Connecticut membership totals at the close of 2009 could affect the ultimate total of any additional payments UnitedHealth might make.

UnitedHealth HMOs fell 29 percent
UnitedHealth Group saw HMO membership drop 29 percent in its Oxford Health Plans subsidiary. Oxford was able to offset that with an 8.2 percent gain in its larger indemnity book of business, however.

Anthem and Oxford Health both had easily the best record in Connecticut on HMO denials of services. Anthem denied a miniscule 4.4 percent of requests for medical service submitted for utilization review, while Oxford Health had a 10.6 percent rate that compared favorably against other carriers.

If approving most treatment requests submitted for utilization review, Anthem also had the second worst record when it came to the percentage of denials that were reversed upon appeal, at 73 percent.

CIGNA had the worst record in the state both on the percentage of utilization review requests that were denied, at 31 percent; and the percentage of those denials that were reversed, at 75 percent.

While Health Net had the second highest percentage of utilization review denials at 25.7 percent, it also had the lowest percentage for denials reversed on appeal, at 31.1 percent.

Along with Aetna and Humana, Wellpoint and UnitedHealth came under Congressional scrutiny this month for allegedly dropping members with pre-existing conditions, Between 2007 and 2009, the four largest for-profit health insurers dropped 651,000 members nationally due to pre-existing conditions, according to a U.S. House of Representatives committee report.

The Patient Protection and Affordable Care Act bans carriers from denying or ending coverage based on pre-existing conditions.