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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. a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a 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 XXX copies of this document were printed at a cost of $XXX.XX or $X.XXX per copy.
Object Description
Description
Title | Managed care in North Carolina : status report & analysis of... activity |
Other Title | ... NC DOI managed care |
Date | 2002-11 |
Description | 2001 activity |
Digital Characteristics-A | 2466 KB; 45 p. |
Digital Format | application/pdf |
Full Text | 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. a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa aa a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a 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 XXX copies of this document were printed at a cost of $XXX.XX or $X.XXX per copy. |
OCLC number | 44501703 |