Managed care in North Carolina : status report & analysis of ... activity

              Analysis of
2001 Activity
Status Report
and
Managed Care
in North Carolina
North Carolina Department of Insurance
Managed Care and Health Benefits Division
November 2002
1
Managed Care in North Carolina
Status Report and Analysis of 2001 Activity
Compiled by the Managed Care and Health Benefits Division
North Carolina Department of Insurance
November 2002
2
Table of Contents
I. Introduction 3-4
About the North Carolina Department of Insurance 3
About the Managed Care and Health Benefits Division 3
Data Sources 3
Other Managed Care Reports Available 4
Other Managed Care Data/Information Available 4
II. 2001 HMO Activity 5-35
Licensed Full-Service HMOs in North Carolina 5
Licensed Single-Service HMOs in North Carolina 6
HMO Profiles 7
Comparative Charts and Tables:
A. HMO Enrollment and Market Share 21
B. HMO Premium Revenues and Medical Expenses 25
C. HMO Inpatient/Outpatient Encounter Data 26
D. HMO Complaints Received by the Department of Insurance 27
E. HMO Utilization Review and Appeals 30
F. HMO Grievances 32
G. HMO Provider Network Summary 35
III. 2001 PPO Plan Activity 36-42
Licensed Insurers Offering PPO Benefit Plans in North Carolina 36
Comparative Charts and Tables:
A. PPO Plan Enrollment 37
B. PPO Plan Complaints Received by the Department of Insurance 37
C. PPO Plan Utilization Review and Appeals 38
D. PPO Plan Grievances 40
IV. Glossary of Managed Care Terms 43
V. Contact Information 44
DISCLAIMER: This document contains data received directly from the HMOs and insurance companies identified within.
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3
I. Introduction
About the North Carolina Department of Insurance
The North Carolina Department of Insurance is responsible for the protection of North Carolina citizens through
the oversight and regulation of insurance companies and agents doing business in the State. In exercising its regula-tory
responsibilities, the Department seeks to ensure a marketplace in which consumers can readily purchase insur-ance
from financially sound and responsive companies, at fair prices, for their lives, health and property.
In addition to regulating the insurance industry, the Department also enforces safety codes and standards and
administers a variety of programs aimed at loss prevention and safety education and awareness throughout the state.
These activities are carried out by the divisions of Engineering and Codes, Fire and Rescue, Manufactured Building,
Prevention Programs and Grants and Special Services. Contact the Department to learn more about these safety and
education activities.
The Department is headed by the Commissioner of Insurance, who is chosen by election every four years. North
Carolina’s current Commissioner of Insurance, Jim Long, is serving his fifth consecutive term since first being
elected in 1984. Commissioner Long also serves as the State Fire Marshal.
About the Managed Care and Health Benefits Division
The Managed Care and Health Benefits Division was established in 1992, to monitor and regulate the activities
of managed care entities, including health maintenance organizations (HMOs), preferred provider organization
benefit plans (PPOs), managed care indemnity health insurers and multiple employer welfare arrangements
(MEWAs). The Division’s focus is on the non-financial aspects of company practices, with special emphasis on
the impact companies’ market practices have on managed care consumers.
In order to deliver the cost controls demanded by purchasers and consumers, managed care organizations apply a
broad array of policies and techniques that have tremendous impact on consumers. Managed care introduced to
the health care delivery system unique company, consumer and provider obligations not inherent in traditional
indemnity insurance. These include requirements relating to provider networks, as well as programs and policies
that insureds and their providers must follow as conditions of coverage for services. The techniques employed by
managed care plans to promote quality care and eliminate unnecessary care, if not applied appropriately, can
become barriers to coverage for the services promised under an insured’s policy. Thus, the Department’s
traditional regulatory oversight of company market practices, treatment of policyholders and solvency are
expanded to include those systems that are unique to managed care plans.
The Division’s primary activities include:
  Coordinating the Department’s review of the licensure and license modifications of HMOs and Multiple
Employer Welfare Arrangements (MEWAs);
  Reviewing annual and initial filings of PPO benefit plans;
  Conducting market practices examinations of HMOs and PPO benefit plans;
  Collecting and reporting HMO and PPO data;
  Approving provider and intermediary form contracts used by HMOs and PPO benefit plans;
  Handling provider complaints about managed care plans; and
  Responding to inquiries about managed care regulation from industry and other interested parties.
Data Sources
Unless otherwise noted, data presented in this report reflect plans’ commercial-insured business only.
��Commercial-insured” refers to those groups and individuals that pay premiums (at contracted rates) to an
insurer, with the insurer accepting financial risk for the cost of covered healthcare services rendered over the
course of the contract period. “Commercial-insured” excludes membership covered under self-funded employer
plans, Federal plans, Medicare and Medicaid.
4
Annual Managed Care Data Filing: By March 1 of each year, all North Carolina-licensed HMOs and PPO
plans are required (under NCGS 58-3-191) to submit an annual managed care data filing to the Department’s
Managed Care and Health Benefits Division. The March 2002 filing, covering the 2001 calendar year, is this
document’s source for data on county-specific commercial-insured enrollment, utilization review activity, appeals,
grievances and provider networks.
Annual Financial Statement: North Carolina law requires licensed HMOs to submit an annual financial
statement to the Department’s Financial Evaluation Division by March 1 of each year. The March 2002 statement,
covering the 2001 calendar year, is this document’s source for data on Statewide commercial-insured enrollment,
premium revenues, medical expenses, inpatient days and outpatient encounters.
Although licensed insurers offering PPO benefit plans also file annual financial statements, financial data specific to
their PPO lines of business are not reported separately. Therefore, the types of financial data listed above for HMOs
are not available for PPO benefit plans.
Department of Insurance Records: The Department’s own records are the source of data on consumer complaints,
provider complaints and HMO service areas. Within this report, the term “complaints” refers to written complaints
sent by consumers and providers to the Department of Insurance, not “appeals” and “grievances” sent directly to
HMOs and PPO plans.
Note: The Department licenses HMOs for specific service areas (N.C. counties), but indemnity insurance companies which
offer PPO benefit plans are licensed to do business on a Statewide basis. Therefore, service areas are not reported for PPO
benefit plans.
The National Committee for Quality Assurance (NCQA): The NCQA evaluates and reports on the quality of
HMOs across the nation. HMO participation in the NCQA accreditation program is voluntary. “Accreditation
Outcomes” reported in the one-page HMO summaries were obtained from NCQA’s website (http://info.ncqa.org/
status.htm), and were current as of 4/15/02. “Excellent” was the highest outcome a plan could receive, meaning the
plan meets or exceeds NCQA’s requirements for consumer protection and quality improvement.
Other Managed Care Reports Available
The 2001 Managed Care Plan Consumer Guide: A Comparison of HMOs and PPO Plans in North Carolina, addresses
the differences between types of managed care plans and contains data on member turnover, provider turnover and
member appeals and grievances for HMO and PPO plans. The guide also contains a comparison of HMOs in
North Carolina based on selected HEDIS data, including member satisfaction and clinical data.
Other Managed Care Data/Information Available
HMO Information:
  Approved service area by HMO
  Enrollment by County, by HMO (as of 12/31 of previous calendar year).
  Providers by County, by HMO (as of 12/31 of previous calendar year).
  Operational/performance data reported by HMOs annually, under authority of NCGS 58-3-191
  HEDIS data reported annually, under authority of NCGS 58-67-50(e)
PPO Carrier Information:
  List of PPO benefit plans
  Enrollment by county, by PPO benefit plan
  Operational/performance data reported by PPOs annually, under authority of NCGS 58-3-191
5
II. 2001 HMO ACTIVITY
Licensed Full-Service HMOs in North Carolina
The number of licensed full-service HMOs in North Carolina peaked at 24 in 1997, and has decreased to 14 since
then. As indicated in Figure 1, three of these HMOs were no longer marketing their products as of 12/31/01. A
fourth HMO was not marketing, but was in the process of seeking the Department’s approval to begin marketing.
Notes:
* No longer a licensed HMO; merged into WellPath on 5/31/02.
** No longer marketing in North Carolina.
***Restricted license; not authorized to market in North Carolina.
Source: N.C. Department of Insurance.
(Figure 1)
Licensed Full-Service HMOs: 12/31/01 (Figure 1)
Company Name Short Name Used in Report
Aetna Health of the Carolinas Inc. Aetna Health
Blue Cross Blue Shield of North Carolina BCBSNC
Carolina Summit Healthcare, Inc.*** Carolina Summit***
CIGNA HealthCare of North Carolina, Inc. CIGNA
Coventry Health Care of the Carolinas, Inc.* Coventry*
Doctors Health Plan, Inc. Doctors
FirstCarolinaCare, Inc. FirstCarolinaCare
One Health Plan of North Carolina, Inc. One Health
Optimum Choice of the Carolinas, Inc. Optimum Choice
Partners National Health Plans of N. C., Inc. Partners
Prudential Health Care Plan, Inc.** Prudential**
QualChoice of North Carolina, Inc.** QualChoice**
UnitedHealthCare of North Carolina, Inc. UnitedHealth
WellPath Select, Inc. WellPath
6
Number of Licensed Full-Service HMOs: 1992-2001 (Figure 2)
Source: N.C. Department of Insurance.
Notes:
Single-Service HMOs are licensed to sell HMO products related to a single-service product line such as dental or vision. However, most of
these plans act as intermediaries for full-service HMOs rather than sell directly to individuals or groups.
Source: N.C. Department of Insurance.
(Figure 3)
Figure 2
10 10
15
18
23
24
23
18
17
14
0
5
10
15
20
25
30
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Licensed Single-Service HMOs in North Carolina: 12/31/01 (Figure 3)
Company Name Toll Free Phone President Address City State Zip
Aetna Dental Inc. Scott Schnuckle 2425 West Loop Houston TX 77027
American Dental Plan of North Carolina, Inc. (800) 633-1262 Phyllis Klock 100 Mansell Court East, Ste. 400 Roswell GA 30076
CIGNA Dental Health of North Carolina, Inc. (800) 367-1037 Ronald Onda P.O. Box 189060 Plantation FL 33318-9060
Spectera Eyecare of North Carolina, Inc. Laurence Manchio 2811 Lord Baltimore Dr. Baltimore MD 21244
7
President:
Address:
Phone:
Medical Director:
Member Toll Free:
Website:
Licensure in NC:
NCQA Accred. Status:
Profit Status:
Most Recent Exam:
HMO Name (HMO Short name)
Commercial-insured enrollment reported in each HMO’s annual
financial statement.
“Medical Loss Ratio” is the percentage of the HMO’s Premium
Revenue spent on Medical & Hospital care.
Plan’s “Premium PMPM” is the average premium collected per-member,
per-month (2001 premium revenue divided by 12/31/01
membership).
Data reported in each HMO’s annual
financial statement. Inpatient encounter
data combine acute medical, surgical,
and maternity stays (excluding mental
health and sub-acute stays). Outpatient/
Ambulatory encounter data combine
office visits, ambulatory surgery and
other procedures, and observation stays
(excluding ER visits).
Grievance and Appeal data reported in
each HMO’s annual data filing, as
required under NCGS 58-3-191.
Complaint data provided by the
Department’s Consumer Services
Division.
Turnover data reported in each HMO’s
annual data filing, as required under
NCGS 58-3-191. Percentages reflect
change from 12/31/00 to 12/31/01.
The Department of Insurance licenses an HMO to market within
specific counties (its “Service Area”), based on provider network
adequacy and other factors. The HMO might choose, however, to
focus its marketing efforts toward specific counties or regions within
the Service Area, at different times.
Full-Service HMO Profiles
(Guide to HMO Profile Layout)
8
President/CEO: John J. Webb
Address: 11675 Great Oaks Way, F350, Alpharetta, GA 30022
Phone: (770) 346-1001
Medical Director: Catherine Eggers Palmer, MD
Member Toll Free: (800) 872-3862
Website: http://www.aetnaushc.com
Licensure in NC: 09/20/95
NCQA Accred. Status: Excellent
Profit Status: For Profit
Most Recent Exam: 03/15/01
Aetna Health of the Carolinas Inc. (Aetna Health)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
*** Company notified NCDOI that it reported incorrect data.
9
President/CEO: Robert J. Greczyn, Jr.
Address: P.O. Box 2291, Durham, NC 27702
Phone: (919) 489-7431
Medical Director: Robert T. Harris, MD
Member Toll Free: (800) 324-4973
Website: http://www.bcbsnc.com
Licensure in NC: 09/02/81
NCQA Accred. Status: Excellent
Profit Status: Not For Profit
Most Recent Exam: 06/14/02
Blue Cross Blue Shield of North Carolina (BCBSNC)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
10
President/CEO: Steven A. White
Address: 701 Corporate Center Drive, Raleigh, NC 27607
Phone: (919) 854-7000
Medical Director: Scott T. Josephs, MD
Member Toll Free: (800) 235-5707
Website: http://www.cigna.com
Licensure in NC: 04/18/86
NCQA Accred. Status: Commendable
Profit Status: For Profit
Most Recent Exam: 06/26/01
CIGNA HealthCare of North Carolina, Inc. (CIGNA)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
11
President/CEO: Tracy H. Baker
Address: c/o WellPath Community Health Plans, 6330 Quad-rangle
Drive, Suite 500, Chapel Hill, NC 27514
Phone: (800) 935-7284
Medical Director: Marty Scott, MD
Member Toll Free: (800) 935-7284
Website: http://www.cvty.com
Licensure in NC: 12/15/94
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 08/29/01
Coventry Health Care of the Carolinas, Inc. (Coventry)
Note: Company merged into WellPath on 5/31/02.
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
12
President/CEO: Steven M. Scott
Address: 3104 Croasdaile Drive, Suite 300, Durham,NC 27705
Phone: (919) 383-4175
Medical Director: J. Patterson Browder, MD
Member Toll Free: (800) 476-2303
Website: http://www.dhpcares.com
Licensure in NC: 09/30/94
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 04/05/02
Doctors Health Plan, Inc. (Doctors)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
13
President/CEO: Kenneth J. Lewis
Address: 315 North Page Road, Commons II, P.O. Box 909,
Pinehurst, NC 28370
Phone: (910) 215-5270
Medical Director: Burt Place, MD
Member Toll Free: (800) 574-8556
Website: http://www.firsthealth.org/firstcarolinacare
Licensure in NC: 11/13/96
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 08/02/02
FirstCarolinaCare, Inc. (FirstCarolinaCare)
NA = Not Applicable
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
14
President/CEO: David E. Record
Address: 6000 Fairview Road, Suite 500, Charlotte, NC 28210
Phone: (704) 552-9642
Medical Director: Deborah Scott, MD
Member Toll Free: (888) 663-8081
Website: http://www.onehealthplan.com/ONEprov.html
Licensure in NC: 07/20/99
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 11/30/01
One Health Plan of North Carolina, Inc. (One Health)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
15
President/CEO: Thomas P. Barbera
Address: 627 Davis Dr., Ste. 100, Morrisville, NC 27560
Phone:
Medical Director: C. Franklin Church, MD
Member Toll Free: (800) 347-1965
Website: http://www.mamsi.com/occi
Licensure in NC: 07/12/95
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 06/23/00
Optimum Choice of the Carolinas, Inc. (Optimum Choice)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
16
President/CEO: James J. Broderick
Address: 2085 Frontis Plaza Boulevard, Winston-Salem, NC 27103
Phone: (336) 760-4822
Medical Director: William Spencer, MD
Member Toll Free: (800) 942-5695
Website: http://www.partnershealth.com
Licensure in NC: 10/30/86
NCQA Accred. Status: Excellent
Profit Status: For Profit
Most Recent Exam: 05/05/00
Partners National Health Plans of North Carolina, Inc. (Partners)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
17
President/CEO: John W. Coyle
Address: 151 Farmington Ave., Hartford, CT 06156
Phone: (860) 273-1771
Medical Director: Andrew Price, MD
Member Toll Free: (800) 643-3609
Website: http://www.aetnaushc.com/pruhealthcare
Licensure in NC: 03/11/85
NCQA Accred. Status: Excellent
Profit Status: For Profit
Most Recent Exam: 02/09/01
Prudential Health Care Plan, Inc. (Prudential)
Note: No longer marketing in North Carolina.
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
18
President/CEO: David Britt Patterson
Address: P. O. Box 340, Winston-Salem, NC 27102-0340
Phone: (336) 716-0900
Medical Director: Alfonso H. Janoski, MD
Member Toll Free: (800) 816-8117
Website: http://www.qualchoicenc.com
Licensure in NC: 09/29/94
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 04/30/01
QualChoice of North Carolina, Inc. (QualChoice)
Note: No longer marketing in North Carolina.
DNR = Did Not Report Required Data
NA = Not Applicable
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
19
President/CEO: Frank Mascia
Address: 3803 N. Elm St., Greensboro, NC 27455
Phone: (336) 282-0900
Medical Director: William Lynagh, MD
Member Toll Free: (800) 772-1180
Website: http://www.unitedhealthcare.com
Licensure in NC: 05/21/85
NCQA Accred. Status: Excellent
Profit Status: For Profit
Most Recent Exam: 09/28/00
UnitedHealthCare of North Carolina, Inc. (UnitedHealth)
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
20
President/CEO: Tracy H. Baker
Address: 6330 Quadrangle Drive, Suite 500, Chapel Hill, NC 27514
Phone: (919) 493-1210
Medical Director: Daniel H. Barco, MD
Member Toll Free: (800) 935-7284
Website: http://www.wellpathchp.com
Licensure in NC: 10/26/95
NCQA Accred. Status:
Profit Status: For Profit
Most Recent Exam: 11/30/01
WellPath Select, Inc. (WellPath)
DNR = Did Not Report Required Data
* Median for North Carolina HMOs
** HMO Financial data not limited to commercial-insured
business; also includes Medicare, Medicaid and/or ASO
business (if applicable).
21
Comparative Charts and Tables
HMOs are required to report enrollment figures to the Department of Insurance. Figures 4 through 11 illustrate
HMO enrollment trends in North Carolina.
A. HMO Enrollment and Market Share
Statewide HMO Enrollment as of Dec. 31 (Figure 4)
Source: Annual Managed Care Data Filings (1996-1999), Annual Financial Statement (2000, 2001)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
Source: Annual Financial Statement (2001)
Statewide Market Share, by HMO: Dec. 31, 2001 (Figure 5)
Figure 4
917,012
1,103,179
1,197,446 1,183,845 1,179,405
1,109,615
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1996 1997 1998 1999 2000 2001
Figure 5
BCB SNC
15%
CIGNA
21%
UnitedHealth
27%
Partners
21%
Doctors
1%
WellP ath
3%
Aetna Health
5%
F irs tCarolinaCare
1%
Optimum Choice
1%
Coventry*
2%
QualChoice**
2%
P rudential**
1%
22
HMO Market Share (Figures 6 through 11)
(Figure 6) (Figure 7)
Notes:
* Merged into WellPath on 5/31/02.
** No longer marketing in North Carolina.
*** Company notified NCDOI that it reported incorrect data.
Source: Annual Financial Statement (2001) (Figure6), Annual Managed Care Data Filings (2001) (Figure 7)
HMO Market Share, Triangle MSA: 12/31/01
HMO Short Name Enrollment Percentage
Aetna Health***
BCBSNC 38,284 17.4%
CIGNA 70,663 32.1%
Coventry* 15 0.0%
Doctors 5,956 2.7%
FirstCarolinaCare 104 0.0%
One Health 534 0.2%
Optimum Choice 3,250 1.5%
Partners 33,602 15.3%
Prudential** 419 0.2%
QualChoice** 31 0.0%
UnitedHealth 48,013 21.8%
Wellpath 19,359 8.8%
Statewide Market Share, by HMO: 12/31/01
HMO Short Name Enrollment Percentage
Aetna Health 54,416 4.9%
BCBSNC 169,904 15.3%
CIGNA 231,046 20.8%
Coventry* 23,026 2.1%
Doctors 10,719 1.0%
FirstCarolinaCare 6,186 0.6%
One Health 1,803 0.2%
Optimum Choice 10,316 0.9%
Partners 235,311 21.2%
Prudential** 9,179 0.8%
QualChoice** 25,687 2.3%
UnitedHealth 298,410 26.9%
Wellpath 33,612 3.0%
23
(Figure 8) (Figure 9)
Notes:
* Merged into WellPath on 5/31/02.
** No longer marketing in North Carolina.
*** Company notified NCDOI that it reported incorrect data.
Source: Annual Managed Care Data Filings (2001)
HMO Market Share, Triad MSA: 12/31/01
HMO Short Name Enrollment Percentage
Aetna Health***
BCBSNC 25,410 10.0%
CIGNA 8,745 3.4%
Coventry* 27 0.0%
Doctors 96 0.0%
FirstCarolinaCare 50 0.0%
One Health 371 0.1%
Optimum Choice 1,996 0.8%
Partners 113,075 44.4%
Prudential** 25 0.0%
QualChoice** 13,119 5.2%
UnitedHealth 89,175 35.0%
Wellpath 2,530 1.0%
HMO Market Share, Charlotte MSA: 12/31/01
HMO Short Name Enrollment Percentage
Aetna Health***
BCBSNC 45,840 20.5%
CIGNA 72,640 32.5%
Coventry* 20,039 9.0%
Doctors 280 0.1%
FirstCarolinaCare 12 0.0%
One Health 556 0.2%
Optimum Choice 4,136 1.9%
Partners 38,489 17.2%
Prudential** 9,776 4.4%
QualChoice** 1,024 0.5%
UnitedHealth 23,624 10.6%
Wellpath 7,063 3.2%
24
(Figure 10) (Figure 11)
Notes:
* Merged into WellPath on 5/31/02.
** No longer marketing in North Carolina.
*** Company notified NCDOI that it reported incorrect data.
Source: Annual Managed Care Data Filings (2001)
HMO Market Share, Other MSAs: 12/31/01
HMO Short Name Enrollment Percentage
Aetna Health***
BCBSNC 32,439 24.7%
CIGNA 27,527 20.9%
Coventry* 94 0.1%
Doctors 308 0.2%
FirstCarolinaCare 75 0.1%
One Health 74 0.1%
Optimum Choice 110 0.1%
Partners 4,737 3.6%
Prudential** 22 0.0%
QualChoice** 1,013 0.8%
UnitedHealth 64,481 49.0%
Wellpath 641 0.5%
HMO Market Share, Non-Metro Counties: 12/31/01
HMO Short Name Enrollment Percentage
Aetna Health***
BCBSNC 26,499 14.9%
CIGNA 43,146 24.2%
Coventry* 1,013 0.6%
Doctors 934 0.5%
FirstCarolinaCare 5,867 3.3%
One Health 246 0.1%
Optimum Choice 975 0.5%
Partners 22,648 12.7%
Prudential** 582 0.3%
QualChoice** 10,564 5.9%
UnitedHealth 62,940 35.3%
Wellpath 2,958 1.7%
“Other” MSAs: Asheville, Fayetteville, Goldsboro, Greenville,
Hickory/Morganton, Jacksonville, Rocky Mount, Wilmington.
25
B. HMO Premium Revenues and Medical Expenses
All North Carolina HMOs are required to submit annual financial reports (the “Annual Statement”) to the
Department’s Financial Evaluation Division. Based on a template developed by the National Association of
Insurance Commissioners (NAIC), the Annual Statement gives plans across the country a standardized financial
reporting format and greatly facilitates the evaluation of an HMO’s solvency and financial condition.
Note: The one-page profiles that are contained in Section II of this publication contain additional financial data for each HMO.
Source: Annual Financial Statement 1996-2001
Statewide HMO Medical Expenses and Premium Revenues: 1996-2001 (Figure 12)
Medical Loss Ratio, by HMO: 1999-2001 (Figure 13)
Notes:
“Medical Loss Ratio” is the percentage of premium revenues that a plan paid out to cover medical expenses. For example, a plan that
pays 90% of its collected premiums to cover member medical expenses would have a medical loss ratio of .90.
Source: Annual Financial Statement 1999-2001
Figure 12
$113
$118
$126
$139 $141
$150
$122 $126
$136
$150
$157
$167
$0
$20
$40
$60
$80
$100
$120
$140
$160
$180
1996 1997 1998 1999 2000 2001
Medical Expenses PMPM Premium Revenue PMPM
Figure 13
0 0.2 0.4 0.6 0.8 1 1.2
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
Aetna Health
NC HMO Median
NC HMO Average (weighted)
1999 2000 2001
26
C. HMO Inpatient/Outpatient Encounter Data
The amount of health care services used by an HMO’s members can be affected by numerous factors, many of
which are beyond the HMO’s control (covered members’ ages, gender, socioeconomic levels, community practice
standards, etc.). When comparing utilization statistics for several plans, therefore, it is important to consider several
possible explanations for whatever differences you might see. For example, if HMO “A” has a higher inpatient
utilization rate than HMO “B,” then HMO “A” might be relatively ineffective at managing chronic conditions.
Another possibility, however, is that HMO “A” has a relatively high proportion of adult female members, leading to
a higher incidence of maternity stays. It is important to remember that the quantity of health care services provided
does not necessarily reflect the quality of an HMO’s delivery system.
Note: Additional utilization statistics can be found on the one-page HMO profiles located in Section II.
Inpatient Days per 10,000 Member Months, by HMO: 2001 (Figure 14)
Outpatient Encounters per 10,000 Member Months, by HMO: 2001 (Figure 15)
Source: Annual Financial Statement (2001)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
Source: Annual Financial Statement (2001)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
DNR = Did Not Report Required Data.
Figure 14
234
203
198
227
231
225
250
337
202
228
202
223
183
225
214
0 50 100 150 200 250 300 350 400
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
Aetna Health
NC HMO Median
NC HMO Average (weighted)
Figure 15
18,468
5,932
6,146
4,750
4,320
7,989
5,018
13,683
2,766
3,119
7,445
5,932
8,735
0 5,000 10,000 15,000 20,000
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
Aetna Health
NC HMO Median
NC HMO Average (weighted)
DNR
DNR
27
D. HMO Complaints Received by the Department of Insurance
North Carolina law requires managed care plans to offer a formal grievance process to their members. However,
managed care plan members may file complaints with the Department’s Consumer Services Division, whether or
not the plan��s grievance process has been utilized. Consumer Services reviews and investigates each complaint to
determine whether the plan has violated applicable State insurance laws, regulations and/or terms of the policy
contract; if such violations and/or fault are found to have occurred, or if the company acknowledges that it was
otherwise at fault, then the complaint is termed “validated.” The Department will take appropriate regulatory
action to require companies to correct any incidences of non-compliance.
Using data provided by the Department’s Consumer Services Division, the first three charts below show the overall
rate of HMO consumer complaints received during 2001 (Figure 16); a breakdown of validated 2001 consumer
complaints by complaint reason (Figure 17); and the rate of validated consumer complaints against each HMO
during 2001 (Figure 18).
Consumer Complaints Against North Carolina HMOs, per 10,000 Member Months: 2001 (Figure 16)
“Validated” NCDOI Consumer Complaints Against North Carolina HMOs, by Reason: 2001 (Figure 17)
Source: N.C. Department of Insurance
Claim Handling – Complaints related to claims payment
amounts, denial, delay, assignment of benefits, coordination of
benefits, etc.
Policyholder Service – Complaints related to customer service,
access to care, quality of care, etc.
Underwriting – Complaints related premiums/rating, cancella-tion,
non-renewal, discrimination, etc.
Marketing & Sales – Complaints related marketing, advertising,
agent conduct,
Source: N.C. Department of Insurance
Figure 16
0.17
0.85
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
All Complaints
Validated Complaints
Figure 17
Claim 
Handling
78%
Underwriting
6%
Policyholder 
Service
15%
Marketing & 
Sales
1%
28
“Validated” Consumer Complaints Against North Carolina HMOs, per 10,000 Member Months: 2001 (Figure 18)
Note:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
***BCBSNC figure represents consumer complaints regarding all lines of business (HMO, PPO, indemnity).
NA: Not Applicable
Source: N.C. Department of Insurance
Figure 18
0.60
0.07
0.17
0.67
0.06
0.33
0.69
0.15
0.47
0.07
0.46
0.11
0.37
0.17
0 0 0 0 0 1 1 1 1
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
***BCBSNC
Aetna Health
NC HMO Median
NC HMO Average
NA
29
Provider Complaints Against North Carolina HMOs, per 1,000 Providers in Each HMO’s Network as of Dec.
31, 2001 (Figure 20)
Note: NA = Not Applicable
Source: N.C. Department of Insurance
Unlike consumer complaints, which are handled by the Consumer Services Division, provider complaints about
managed care plans are handled by the Managed Care and Health Benefits Division. The two charts below show a
breakdown of validated provider complaints filed in 2001, by reason (Figure 19), and the rate of validated provider
complaints filed against each HMO during 2001 (Figure 20).
Validated Provider Complaints Against North Carolina HMOs, by Reason: 2001 (Figure 19)
Source: N.C. Department of Insurance
Claims Processing- Complaints regarding claim
denials, accuracy and/or timeliness of reimburse-ment,
etc.
Provider Network- Complaints regarding a plan’s
network adequacy, credentialing program, provider
directory listings, provider contract, etc.
Utilization Review- Complaints regarding a plan’s
handling of authorizations, medical necessity
decisions, appeals, and/or utilization review
program in general.
Miscellaneous- Other complaints not included in
categories above.
Figure 19
Claims 
Processing
76%
Utilization 
Review
11%
Provider 
Network
8%
Miscellaneous
5%
Source: N.C. Department of Insurance
Figure 20
2.41
2.56
1.02
3.30
0.32
0.18
0.00
0.19
4.08
4.49
0.00
3.70
0.63
0.70
0.20
0.66
0.00
0.00
0.00
0.00
0.51
0.46
0.00
0.82
0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
Aetna Health
All Provider Complaints Validated Provider Complaints
NA
30
E. HMO Utilization Review and Appeals
Under NCGS 58-50-61(a)(17), “utilization review” (UR) is defined as a set of formal techniques designed to
monitor the use of or evaluate the clinical necessity, appropriateness, efficacy or efficiency of health care services,
procedures, providers or facilities. Such techniques could include case management as well as prospective,
concurrent and retrospective reviews. There can be considerable differences in how each HMO performs its
utilization review activities.
When a health plan’s utilization review process determines that a requested health care service is not medically
necessary, the affected member has the right to file an appeal, asking the health plan to overturn the initial denial
decision (or “noncertification”). A member may also file a second-level grievance if the HMO’s response to the
appeal is not satisfactory.
Percentage of Utilization Reviews Resulting in Noncertification, by HMO: 2001 (Figures 21 and 22)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
***Company notified NCDOI that it
reported incorrect data.
Source: Annual Managed Care Data
Filings 2001
Figure 22
7.8%
1.5%
4.8%
0.5%
8.8%
3.8%
1.6%
0.1%
4.1%
9.1%
8.4%
3.3%
4.0%
6.0%
0 0.02 0.04 0.06 0.08 0.1
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
***Aetna Health
NC HMO Median
NC HMO Average (weighted)
Percentage of Utilization Reviews Resulting in Noncertification, by HMO: 2001 (Figure 21)
Company Name Reviews Performed Percent
NC HMO Average (weighted) 6.0%
NC HMO Median 4.0%
Aetna Health***
BCBSNC 37,554 3.3%
CIGNA 97,978 8.4%
Coventry* 19,678 9.1%
Doctors 9,988 4.1%
FirstCarolinaCare 10,273 0.1%
One Health 381 1.6%
Optimum Choice 3,792 3.8%
Partners 82,591 8.8%
Prudential** 30,643 0.5%
QualChoice** 10,018 4.8%
UnitedHealth 54,522 1.5%
Wellpath 43,439 7.8%
31
Percentage of First-Level Appeals Resolved in Members’ Favor, by HMO: 2001 (Figures 23 and 24)
Percentage of First-Level Appeals Resolved in Members' Favor, by HMO: 2001 (Figure 23)
Company Name Noncertifications Appealed Percent
NC HMO Average (weighted) 40.9%
NC HMO Median 33.3%
Aetna Health***
BCBSNC 174 44.8%
CIGNA 943 37.1%
Coventry* 234 26.9%
Doctors 19 26.3%
FirstCarolinaCare 4 25.0%
One Health 0 NA
Optimum Choice 6 33.3%
Partners 1,015 59.0%
Prudential** 25 36.0%
QualChoice** 209 39.7%
UnitedHealth 124 19.4%
Wellpath 425 20.2%
Figure 24
20.2%
19.4%
39.7%
36.0%
59.0%
33.3%
25.0%
26.3%
26.9%
37.1%
44.8%
33.3%
40.9%
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
***Aetna Health
NC HMO Median
NC HMO Average (weighted)
NA
Notes:
NA = Not Applicable
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
***Company notified NCDOI that it reported incorrect data.
Source: Annual Managed Care Data Filings 2001
32
F. HMO Grievances
As defined in NCGS 58-50-61(a)(6), a grievance is any written complaint regarding a plan’s decisions or policies
relating to health care delivery, availability or quality; claims payment/processing or reimbursement for services; the
contractual relationship between a covered person and the plan or the outcome of an appeal of a noncertification. A
member may file a second-level grievance if the HMO’s response to the initial grievance is not satisfactory.
Note that these data do not include second-level grievances relating to UR decisions; those grievances are reported as
“appeals.”
Not all grievances result from unfair policies or incorrect decisions by HMOs. For example, a member’s complaint
might have resulted from his/her not following the HMO’s procedures for obtaining services. Therefore, the
number or rate of grievances received does not necessarily indicate the quality of an HMO or the satisfaction level
of its members.
First-Level Grievances per 10,000 Member Months, by HMO: 2001 (Figures 25 and 26)
First-Level Grievances per 10,000 Member Months, by HMO: 2001 (Figure 25)
Company Name Grievances Received
Grievances per 10,000
Member Months
NC HMO Average (weighted) 2.3
NC HMO Median 2.9
Aetna Health***
BCBSNC 163 1.0
CIGNA 293 1.1
Coventry* 147 4.3
Doctors 27 2.0
FirstCarolinaCare 12 1.8
One Health 3 1.0
Optimum Choice 70 5.7
Partners 1,079 3.8
Prudential** 192 9.9
QualChoice** 304 8.7
UnitedHealth 383 1.1
Wellpath 278 3.7
Figure 26
3.7
1.1
8.7
9.9
3.8
5.7
1.0
1.8
2.0
4.3
1.1
1.0
2.9
2.3
0 2 4 6 8 10 12
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
***Aetna Health
NC HMO Median
NC HMO Average (weighted)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
***Company notified NCDOI that it reported
incorrect data.
Source: Annual Managed Care Data Filings 2001
33
First-Level Grievances, by Reason: 2001 (Figure 27)
Note:
* Excludes Aetna Health of the Carolinas, Inc. (notified the Department that it reported incorrect data).
Source: Annual Managed Care Data Filings 2001
Access to Care — Grievances about the availability of in-network providers (appointment wait times; driving
distance; etc.)
Authorization/Referral/Precert — Grievances about problems with authorization for services.
Benefits — Grievances about coverage limits, copayments/coinsurance, exclusion, etc.
Claims — Grievances about the timeliness and/or accuracy of claims processing.
Enrollment/Eligibility — Grievances about the accuracy of Plan’s enrollment/eligibility information, and/or
about difficulty accessing that information.
Quality of Care/Service — Grievances about the quality of care rendered by in-network providers, provider/
staff behavior, etc.
Figure 27
Claims
39%
Access to 
Care
12%
Other
11%
Enrollmt./ 
Eligibility
1%
Quality of 
Care/ Service
1%
Auth/ 
Referral/ 
Precert
13%
Benefits
23%
34
Percentage of First-Level Grievances Resolved in Members’ Favor, by HMO: 2001 (Figures 28 and 29)
Percentage of First-Level Grievances Resolved in
Members' Favor, by HMO: 2001 (Figure 28)
Company Name Percent
NC HMO Average (weighted) 65.1%
NC HMO Median 63.2%
Aetna Health***
BCBSNC 60.7%
CIGNA 45.7%
Coventry* 73.5%
Doctors 77.8%
FirstCarolinaCare 41.7%
One Health 100.0%
Optimum Choice 45.7%
Partners 83.4%
Prudential** 64.6%
QualChoice** 61.8%
UnitedHealth 29.0%
Wellpath 70.9%
Figure 29
70.9%
29.0%
61.8%
64.6%
83.4%
45.7%
100.0%
41.7%
77.8%
73.5%
45.7%
60.7%
63.2%
65.1%
0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0%
WellPath
UnitedHealth
**QualChoice
**Prudential
Partners
Optimum Choice
One Health
FirstCarolinaCare
Doctors
*Coventry
CIGNA
BCBSNC
***Aetna Health
NC HMO Median
NC HMO Average (weighted)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
***Company notified NCDOI that it reported incorrect data.
Source: Annual Managed Care Data Filings 2001
35
G. HMO Provider Network Summary
Because HMO members are either required to obtain their health care services from “in-network” providers, or
given strong financial incentives to do so, it is essential that HMO provider networks contain adequate numbers of
providers with appropriate appointment availability, and whose locations are reasonably convenient for covered
members. HMOs are required to establish standards for provider appointment availability and geographic accessibil-ity,
and networks must be continuously monitored with respect to those standards.
The table below shows the 2001 Geographic Accessibility standards held by each HMO in 2001, expressed as the
number of providers within a specific driving distance. (Example: “2:10” indicates a standard of two providers
within 10 miles of each covered member.)
Geographic Provider Accessibility Standards, by HMO: 2001 (Figure 30)
Notes:
*Merged into WellPath on 5/31/02.
**No longer marketing in North Carolina.
NA = Not Applicable.
HMOs are not required to have separate standards for urban vs. suburban vs. rural areas.
Source: Annual Managed Care Data Filings 2001
(figure 30)
36
III. 2001 PPO Plan Activity
Licensed Insurers Offering PPO Benefit Plans in North Carolina
PPO benefit plans are products offered by licensed indemnity carriers. Figure 31 shows the licensed indemnity
carriers that were offering full-service PPO Benefit Plans in North Carolina, as of Dec. 31, 2001.
Note:
*No longer marketing a PPO product in North Carolina.
**Company notified NCDOI that it reported incorrect data.
Source: N.C. Department of Insurance
(figu(Figure 31)re 31)
Due to differences in the laws and reporting requirements that apply to HMOs vs. indemnity carriers, some of the
data presented in the HMO section of this Report are not available for PPO benefit plans. For example, an insur-ance
company files an annual financial statement to report its overall financial condition, but this statement does
not contain data focused solely on the company’s PPO product. Similarly, only HMOs are subject to the annual
HEDIS/CAHPS reporting requirement under NCGS 58-67-50(e). Conversely, both HMOs and PPO carriers are
subject to the annual managed care data reporting requirements set forth in NCGS 58-3-191 (covering utilization
review activity, grievances, provider networks, and other operational data).
(Figure 31) (Figure 31)
37
Comparative Charts and Tables
A. PPO Plan Enrollment
Statewide PPO Plan Enrollment as of Dec. 31 (Figure 32)
* Excludes Mutual of Omaha Insurance Company (notified the Department that it reported incorrect data).
Source: Annual Managed Care Data Filings (1997-2001).
B. PPO Plan Complaints Received by the Department of Insurance
Validated Provider Complaints Against PPO Plans, by Reason: 2001 (Figure 33)
Source:  N.C. Department of Insurance
Figure 32
584,764 559,551
600,331
756,356 743,761
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
1997 1998 1999 2000 2001*
Figure 33
Claims 
Processing
50%
Utilization 
Review
17%
Miscellaneous
8%
Provider 
Netw ork
25%
Claims- Complaints regarding claim denials,
accuracy and/or timeliness of reimburse-ment,
etc.
Provider Network- Complaints regarding a
plan’s network adequacy, credentialing
program, provider directory listings, provider
contract, etc.
Utilization Review- Complaints regarding a
plan’s handling of authorizations, medical
necessity decisions, appeals, and/or utiliza-tion
review program in general.
Miscellaneous- Other complaints not
included in categories above.
38
C. PPO Plan Utilization Review and Appeals
(Figure 35) - This chart is based on data from Figure 34 for PPO plans with greater than 10,000 members on Dec. 31, 2001.
Percentage of Utilization Reviews Resulting in
Noncertification, by PPO Carrier: 2001 (Figure 34)
Company Name Reviews Percent
NC PPO Plan Average (weighted) 4.0%
NC PPO Plan Median 2.1%
Aetna Life Insurance Company 12,207 0.9%
Alta Health & Life Insurance Company 0 NA
American Republic Insurance Company 511 6.1%
Avemco Insurance Company 41 0.0%
Benchmark Insurance Company 0 NA
Blue Cross & Blue Shield of North Carolina 49,759 2.3%
Celtic Insurance Company 368 4.9%
Connecticut General Life Insurance Company 33,036 9.3%
Conseco Medical Insurance Company* 3,700 0.2%
Coventry Health and Life Insurance Company 2,513 1.4%
Federated Mutual Insurance Company 192 6.3%
Fortis Benefits Insurance Company 798 3.5%
Fortis Insurance Company 1,194 9.1%
GE Group Life Assurance Company 440 2.7%
Great-West Life & Annuity Insurance Company 152 3.9%
Guardian Life Insurance Company of America 6,554 0.7%
Company Name Reviews Percent
Humana Insurance Company 5,054 2.3%
John Alden Life Insurance Company 1,540 1.8%
MAMSI Life and Health Insurance Company 13,175 4.2%
Mega Life and Health Insurance Company 0 NA
Mid-West National Life Insurance Company of Tennessee 0 NA
Mutual of Omaha Insurance Company**
New England Life Insurance Company 25 0.0%
Pacific Life & Annuity Company 1,068 0.1%
Philadelphia American Life Insurance Company 181 0.0%
Pioneer Life Insurance Company* 194 1.0%
Principal Life Insurance Company 4,340 4.7%
Prudential Insurance Company of America 75 0.0%
Transamerica* (formerly PFL Life) 0 NA
Trustmark Insurance Company 734 5.3%
UniCARE Life & Health Insurance Company 1,174 1.1%
United HealthCare Insurance Company 215 0.0%
United of Omaha Life Insurance Company 14 21.4%
United Wisconsin Life Insurance Company 2,469 2.0%
United World Life Insurance Company* 0 NA
World Insurance Company 0 NA
Figure 35
1.1%
5.3%
4.7%
4.2%
2.3%
0.7%
9.1%
0.2%
9.3%
2.3%
2.1%
4.0%
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
World Insurance Company
UniCARE Life & Health Insurance Company
Trustmark Insurance Company
Principal Life Insurance Company
Mega Life and Health Insurance Company
MAMSI Life and Health Insurance Company
Humana Insurance Company
Guardian Life Insurance Company of America
Fortis Insurance Company
*Conseco Medical Insurance Company
Connecticut General Life Insurance Company
Blue Cross & Blue Shield of North Carolina
NC PPO Plan Median
NC PPO Plan Average (weighted)
NA
NA
Notes:  NA = Not Applicable (no utilization reviews in 2001), *No longer marketing a PPO product in North Carolina, **Company
notified NCDOI that it reported incorrect data
Source:  Annual Managed Care Data Filings 2001.
39
(Figure 37) - This chart is based on data from Figure 36 for PPO plans with greater than 10,000 members on Dec. 31, 2001.
Percentage of First-Level Appeals in Members'
Favor, by PPO Carrier: 2001 (Figure 36)
Company Name Appeals Percent
NC PPO Plan Average (weighted) 36.8%
NC PPO Plan Median 33.3%
Aetna Life Insurance Company 2 50.0%
Alta Health & Life Insurance Company 0 NA
American Republic Insurance Company 3 66.7%
Avemco Insurance Company 0 NA
Benchmark Insurance Company 0 NA
Blue Cross & Blue Shield of North Carolina 51 31.4%
Celtic Insurance Company 0 NA
Connecticut General Life Insurance Company 115 44.3%
Conseco Medical Insurance Company* 7 0.0%
Coventry Health and Life Insurance Company 9 11.1%
Federated Mutual Insurance Company 2 100.0%
Fortis Benefits Insurance Company 10 20.0%
Fortis Insurance Company 24 20.8%
GE Group Life Assurance Company 1 0.0%
Great-West Life & Annuity Insurance Company 1 0.0%
Guardian Life Insurance Company of America 10 50.0%
Company Name Appeals Percent
Humana Insurance Company 10 30.0%
John Alden Life Insurance Company 6 16.7%
MAMSI Life and Health Insurance Company 24 37.5%
Mega Life and Health Insurance Company 0 NA
Mid-West National Life Insurance Company of Tennessee 0 NA
Mutual of Omaha Insurance Company**
New England Life Insurance Company 0 NA
Pacific Life & Annuity Company 0 NA
Philadelphia American Life Insurance Company 0 NA
Pioneer Life Insurance Company* 0 NA
Principal Life Insurance Company 31 35.5%
Prudential Insurance Company of America 0 NA
Transamerica* (formerly PFL Life) 0 NA
Trustmark Insurance Company 6 33.3%
UniCARE Life & Health Insurance Company 0 NA
United HealthCare Insurance Company 0 NA
United of Omaha Life Insurance Company 3 33.3%
United Wisconsin Life Insurance Company 11 72.7%
United World Life Insurance Company* 0 NA
World Insurance Company 0 NA
Notes:  NA = Not Applicable (no appeals in 2001), *No longer marketing a PPO product in North Carolina, **Company notified
NCDOI that it reported incorrect data
Source:  Annual Managed Care Data Filings 2001.
Figure 37
33.3%
35.5%
37.5%
30.0%
50.0%
20.8%
44.3%
31.4%
33.3%
36.8%
0% 10% 20% 30% 40% 50% 60%
World Insurance Company
UniCARE Life & Health Insurance Company
Trustmark Insurance Company
Principal Life Insurance Company
Mega Life and Health Insurance Company
MAMSI Life and Health Insurance Company
Humana Insurance Company
Guardian Life Insurance Company of America
Fortis Insurance Company
*Conseco Medical Insurance Company
Connecticut General Life Insurance Company
Blue Cross & Blue Shield of North Carolina
NC PPO Plan Median
NC PPO Plan Average (weighted)
NA
NA
NA
NA
40
(Figure 39) - This chart is based on data from Figure 38 for PPO plans with greater than 10,000 members on Dec. 31, 2001.
Figure 39
79.3
11.1
4.0
17.2
0.5
49.9
95.2
3.9
199.5
6.8
13.4
10.2
15.1
26.1
0 50 100 150 200 250
World Insurance Company
UniCARE Life & Health Insurance Company
Trustmark Insurance Company
Principal Life Insurance Company
Mega Life and Health Insurance Company
MAMSI Life and Health Insurance Company
Humana Insurance Company
Guardian Life Insurance Company of America
Fortis Insurance Company
*Conseco Medical Insurance Company
Connecticut General Life Insurance Company
Blue Cross & Blue Shield of North Carolina
NC PPO Plan Median
NC PPO Plan Average (weighted)
Notes:  NA = Not Applicable (no members on 12/31/01), *No longer marketing a PPO product in North Carolina, **Company notified
NCDOI that it reported incorrect data
Source:  Annual Managed Care Data Filings 2001.
First-Level Grievances Per 10,000 Members, by
PPO Carrier: 2001 (Figure 38)
Company Name Grievances Rate
NC PPO Plan Average (weighted) 26.1
NC PPO Plan Median 15.1
Aetna Life Insurance Company 2 7.5
Alta Health & Life Insurance Company 0 0.0
American Republic Insurance Company 12 16.3
Avemco Insurance Company 0 0.0
Benchmark Insurance Company 4 97.3
Blue Cross & Blue Shield of North Carolina 411 10.2
Celtic Insurance Company 5 11.9
Connecticut General Life Insurance Company 24 13.4
Conseco Medical Insurance Company* 17 6.8
Coventry Health and Life Insurance Company 24 1,463.4
Federated Mutual Insurance Company 0 0.0
Fortis Benefits Insurance Company 147 233.1
Fortis Insurance Company 168 199.5
GE Group Life Assurance Company 1 15.1
Great-West Life & Annuity Insurance Company 0 0.0
Guardian Life Insurance Company of America 19 3.9
Company Name Grievances Rate
Humana Insurance Company 227 95.2
John Alden Life Insurance Company 55 101.0
MAMSI Life and Health Insurance Company 177 49.9
Mega Life and Health Insurance Company 1 0.5
Mid-West National Life Insurance Company of Tennessee 0 0.0
Mutual of Omaha Insurance Company**
New England Life Insurance Company 70 885.0
Pacific Life & Annuity Company 252 377.9
Philadelphia American Life Insurance Company 11 80.3
Pioneer Life Insurance Company* 3 22.3
Principal Life Insurance Company 94 17.2
Prudential Insurance Company of America 7 97.8
Transamerica* (formerly PFL Life) 0 0.0
Trustmark Insurance Company 6 4.0
UniCARE Life & Health Insurance Company 12 11.1
United HealthCare Insurance Company 4 5.0
United of Omaha Life Insurance Company 32 NA
United Wisconsin Life Insurance Company 33 42.1
United World Life Insurance Company* 0 NA
World Insurance Company 124 79.3
D. PPO Plan Grievances
41
First-Level Grievances, by Reason: 2001 (Figure 40)
* Excludes Mutual of Omaha Insurance Company (notified the Department that it reported incorrect data).
Source: Annual Managed Care Data Filings 2001
Access to Care — Grievances about the availability of in-network providers (appointment wait times; driving
distance; etc.)
Authorization/Referral/Precert — Grievances about problems with authorization for services.
Benefits — Grievances about coverage limits, copayments/coinsurance, exclusion, etc.
Claims — Grievances about the timeliness and/or accuracy of claims processing.
Enrollment/Eligibility — Grievances about the accuracy of Plan’s enrollment/eligibility information, and/or
about difficulty accessing that information.
Quality of Care/Service — Grievances about the quality of care rendered by in-network providers, provider/
staff behavior, etc.
Figure 40
Claims
45%
Access to 
Care
2%
Benefits
34%
Quality of 
Care/ 
Service
1%
Enrollmt./ 
Eligibility
1%
Other
Auth/  14%
Referral/ 
Precert
3%
42
(Figure 42) - This chart is based on data from Figure 41 for PPO plans with greater than 10,000 members on Dec. 31, 2001.
Percentage of First-Level Grievances Resolved
in Members' Favor, by PPO Carrier: 2001
(Figure 41)
Company Name Percent
NC PPO Plan Average (weighted) 42.3%
NC PPO Plan Median 47.4%
Aetna Life Insurance Company 100.0%
Alta Health & Life Insurance Company NA
American Republic Insurance Company 58.3%
Avemco Insurance Company NA
Benchmark Insurance Company 75.0%
Blue Cross & Blue Shield of North Carolina 47.9%
Celtic Insurance Company 20.0%
Connecticut General Life Insurance Company 29.2%
Conseco Medical Insurance Company* 76.5%
Coventry Health and Life Insurance Company 70.8%
Federated Mutual Insurance Company NA
Fortis Benefits Insurance Company 14.3%
Fortis Insurance Company 13.1%
GE Group Life Assurance Company 0.0%
Great-West Life & Annuity Insurance Company NA
Guardian Life Insurance Company of America 73.7%
Company Name Percent
Humana Insurance Company 81.5%
John Alden Life Insurance Company 10.9%
MAMSI Life and Health Insurance Company 29.9%
Mega Life and Health Insurance Company 100.0%
Mid-West National Life Insurance Company of Tennessee NA
Mutual of Omaha Insurance Company**
New England Life Insurance Company 47.1%
Pacific Life & Annuity Company 51.2%
Philadelphia American Life Insurance Company 27.3%
Pioneer Life Insurance Company* 33.3%
Principal Life Insurance Company 19.1%
Prudential Insurance Company of America 57.1%
Transamerica* (formerly PFL Life) NA
Trustmark Insurance Company 50.0%
UniCARE Life & Health Insurance Company 16.7%
United HealthCare Insurance Company 50.0%
United of Omaha Life Insurance Company 21.9%
United Wisconsin Life Insurance Company 36.4%
United World Life Insurance Company* NA
World Insurance Company 47.6%
Figure 42
47.6%
16.7%
50.0%
19.1%
100.0%
29.9%
81.5%
73.7%
13.1%
76.5%
29.2%
47.9%
47.4%
42.3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
World Insurance Company
UniCARE Life & Health Insurance Company
Trustmark Insurance Company
Principal Life Insurance Company
Mega Life and Health Insurance Company
MAMSI Life and Health Insurance Company
Humana Insurance Company
Guardian Life Insurance Company of America
Fortis Insurance Company
Conseco Medical Insurance Company*
Connecticut General Life Insurance Company
Blue Cross & Blue Shield of North Carolina
NC PPO Plan Median
NC PPO Plan Average (weighted)
Notes:  NA = Not Applicable (no grievances in 2001), *No longer marketing a PPO product in North Carolina, **Company notified
NCDOI that it reported incorrect data
Source:  Annual Managed Care Data Filings 2001.
43
IV. Glossary of Managed Care Terms
Commercial-insured – Refers to those groups and individuals that pay premiums (at contracted rates) to an insurer,
with the insurer accepting financial risk for the cost of covered healthcare services rendered over the course of the
contract period. “Commercial-insured” excludes membership covered under self-funded employer plans, Federal
plans, Medicare and Medicaid.
Grievance - A written complaint from a member.
Medical Loss Ratio - Ratio of medical expenses to premium revenue. For example, a Medical Loss Ratio of .93
indicates that for every dollar received as premium revenue, $0.93 is spent on medical expenses.
Member - A person covered under a health insurance plan.
NCQA Accreditation - See Section I, “Data Sources.”
PMPM - Per Member/ Per Month
Provider - A doctor, hospital, or other health care professional or facility.
Provider Network - The doctors, hospitals, and other health care professionals or facilities under contract with a
health plan.
UR - Utilization Review – The process by which a managed care plan examines health care services to ensure that
they are medically necessary.
UR Appeal - A written request for a plan to reverse its utilization review decision to deny coverage of a service.
44
V. Contact Information
North Carolina Department of Insurance
Consumer Services Division
P.O. Box 26387
Raleigh, NC 27611
1-800-546-5664
Managed Care and Health Benefits Division
111 Seaboard Avenue
Raleigh, NC 27604
(919) 715-0526
(919) 715-0198 Fax
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