New York Consumer Guide to Health Insurance Companies. New York State Andrew M. Cuomo, Governor

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1 New York Consumer Guide to Health Insurance Companies 2012 New York State Andrew M. Cuomo, Governor

2 Table of Contents ABOUT THIS GUIDE... 2 COMPLAINTS... 3 PROMPT PAY COMPLAINTS... 8 INTERNAL APPEALS EXTERNAL APPEALS ACCESS AND SERVICE CHILD AND ADOLESCENT HEALTH ADULT HEALTH DIABETES BEHAVIORAL HEALTH QUALITY OF PROVIDERS GRIEVANCES HMO ACCREDITATION HOW HMOS PAY PRIMARY CARE PHYSICIANS OVERALL COMPLAINT RANKING TELEPHONE NUMBERS FOR HEALTH INSURANCE COMPANIES CONTACTS AND RESOURCES

3 New York Consumer Guide to Health Insurance Companies About This Guide The purpose of this Guide is to: Inform you of the health insurance products offered in New York State and how they work. Help you choose a health insurance company based on quality of care and service. Data Sources The information in this Guide comes from two New York agencies. 1. New York State Department of Financial Services (NYS DFS) is responsible for protecting the public interest by supervising and regulating financial products and services, including those subject to the provisions of the Insurance Law and the Banking Law in New York State. NYS DFS compiles the complaint and appeal information that appears on pages 3 22 as well as the grievance information that appears on pages NYS DFS data are from calendar year New York State Department of Health (NYS DOH) works to protect and promote the health of New Yorkers through prevention, science and ensuring delivery of quality health care. NYS DOH compiles the complaint data on page 4 and the information on HMO performance that appears on pages NYS DOH collects data through the New York State Department of Health s Quality Assurance Reporting Requirements (QARR) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS ). 1 NYS DOH data on quality of care and service for HMOs are from calendar year 2010, except where noted. Details About the Data The Guide does not include: o HMOs with less than $25 million in premiums or fewer than 5,000 members. o Commercial and non-profit companies with less than $50 million in premiums. o Data for Medicare, Medicaid or self-insured plans. 2 Health insurance companies are listed alphabetically in the data tables, except for the Overall Complaint Ranking table on pages Some health insurance company names are listed using different names depending on whether the data are reported by NYS DFS or NYS DOH. 1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 2 For information about Medicare coverage, call the Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees this program, at 800-MEDICARE ( ), or visit the Web site at You can also contact the New York State Office for the Aging Health Insurance Information Counseling & Assistance Program (HIICAP) by calling or visit the Web site at For information on New York s Medicaid program, contact your local county Department of Social Services. 2

4 Each year, New York State (NYS DFS or NYS DOH) receives complaints about health insurance companies from consumers and health care providers. After reviewing each complaint, the State determines if the health insurance company acted appropriately. If the State determines that the health insurance company did not act in accordance with their statutory and contractual obligations, the company must resolve the problem. typically involve issues related to prompt payment, reimbursement, coverage, benefits, rates and premiums. For issues concerning payment, reimbursement, coverage, benefits, rates and premiums, contact NYS DFS at Understanding the Charts Rank: Each health insurance company is ranked based on how many complaints were resolved in favor of the consumer or provider by NYS DFS, relative to the health insurance company s premium. A lower number is better. If the ratios are the same, the health insurance company with the higher premium is ranked higher. Total to NYS DFS: Total number of complaints closed by NYS DFS in Large health insurance companies may receive more complaints because they have more consumers than smaller health insurance companies. Upheld by NYS DFS: Number of closed complaints resolved in favor of the consumer or provider because the NYS DFS determined that the health insurance company did not comply with statutory or contractual obligations. Upheld complaints by the NYS DFS are used to calculate the complaint ratio and rank. Premiums: Dollar amount generated by a health insurance company in New York State during Premiums are used to calculate the complaint ratio so that the health insurance companies of different sizes can be compared fairly. Premium data exclude Medicare and Medicaid. Complaint Ratio: Number of upheld complaints (complaints resolved in favor of the consumer or provider) by NYS DFS, divided by the health insurance company s premium. Total to NYS DOH: Total number of complaints against HMOs closed by NYS DOH. Upheld to NYS DOH: Number of complaints closed by NYS DOH that were decided in favor of the consumer or provider. 3

5 - HMOs 2011 Data Source: NYS DFS and NYS DOH HMO 1 HMOs with a lower complaint ratio receive a better rank. Rank 1 1 = Best 11 = Worst Data Compiled by the New York State Department of Financial Services (NYS DFS) Total to NYS DFS Upheld by NYS DFS Premiums (Millions $) Complaint Ratio Data Compiled by the NYS Department of Health (NYS DOH) Total to NYS DOH Upheld by NYS DOH Aetna Health Inc Atlantis Health Plan, Inc. 11 1, CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus Health Plan HIP HMO , Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans (NY), Inc , UnitedHealthcare of New York, Inc Total 3,589 1,774 7,

6 - Non-profit Indemnity Health Insurance Companies 2011 Data Source: NYS DFS Non-profit Indemnity Health Insurance Company Rank 1 1 = Best 5 = Worst Total to NYS DFS Upheld by NYS DFS Premiums (Millions $) Complaint Ratio CDPHP Universal Benefits, Inc Excellus Health Plan, Inc , Group Health Incorporated 5 2,309 1,122 3, Healthnow New York Inc , Independent Health Benefits Corporation Total 3,006 1,502 9, Health insurance companies with a lower complaint ratio receive a better rank. 5

7 - Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company Rank 1,2 1 = Best 38 = Worst Total to NYS DFS Upheld by NYS DFS Premiums (Millions $) Complaint Ratio Aetna Life Insurance Company , American Family Life Assurance Company of New York American Progressive Life and Health Insurance Berkshire Life Insurance Company of America CIGNA Life Insurance Company of New York Combined Life Insurance Company of New York Connecticut General Life Insurance Company Delta Dental Insurance Company Empire HealthChoice Assurance, Inc , First Rehabilitation Life Insurance Company of America First Unum Life Insurance Company Freelancers Insurance Company, Inc Genworth Life Insurance Company of New York Guardian Life Insurance Company of America Hartford Life Insurance Company HIP Insurance Company of New York Humana Insurance Company of New York John Hancock Life & Health Insurance Company Massachusetts Mutual Life Insurance Company If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a better rank. 2 Health insurance companies with a lower complaint ratio receive a better rank. 3 Plan issues dental coverage only. 6

8 Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company Rank 1,2 1 = Best 38 = Worst Total to NYS DFS Upheld by NYS DFS Premiums (Millions $) Complaint Ratio Medco Containment Insurance Company of New York Metropolitan Life Insurance Company Mutual of Omaha Insurance Company MVP Health Insurance Company National Union Fire Insurance Company of Pittsburgh, PA New York Life Insurance Company Nippon Life Insurance Company of America Northwestern Mutual Life Insurance Company Oxford Health Insurance, Inc. 26 1, , Paul Revere Life Insurance Company Prudential Insurance Company of America Standard Life Insurance Company of New York Standard Security Life Insurance Company of New York Sterling Life Insurance Company Sun Life Insurance and Annuity Company of New York Transamerica Financial Life Insurance Company United States Life Insurance Company in the City of New York UnitedHealthcare Insurance Company of New York , Zurich American Insurance Company Total 4,310 1,340 24, If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a better rank. 2 Health insurance companies with a lower complaint ratio receive a better rank. 7

9 Prompt Pay New York State requires all health insurance companies to: Pay undisputed electronic claims within 30 days and pay undisputed claims within 45 days of receipt, or Request all additional information from the consumer or the provider, if necessary, within 30 days of receipt of the claims, or Deny the claim within 30 days of receipt. NYS DFS has a dedicated hotline for consumers and providers to file prompt pay complaints at Understanding the Charts Rank: Each health insurance company is ranked based on the number of upheld prompt pay complaints, relative to the health insurance company premium. A lower number is better. If the ratios are the same, the health insurance company with the higher premium is ranked higher. Total : Total number of complaints closed by the NYS DFS in typically involve issues about prompt payment, reimbursement, coverage, benefits, rates and premiums. Total Prompt Pay : Total number of prompt pay complaints closed by the NYS DFS in Large health insurance companies might receive more complaints because they have more consumers and pay more claims than smaller health insurance companies. Upheld Prompt Pay : Number of closed prompt pay complaints where the NYS DFS determined the health insurance company was not processing claims in a timely manner. Upheld prompt pay complaints by the NYS DFS are used to calculate the prompt pay complaint ratio and rank. Premiums: Dollar amount generated by a health insurance company in New York State in Premiums are used to calculate the prompt pay complaint ratio so that health insurance companies of different sizes can be compared fairly. Premium data exclude Medicare and Medicaid. Prompt Pay Complaint Ratio: Number of upheld prompt pay complaints divided by a health insurance company s premium. 8

10 Prompt Pay - HMOs 2011 Data Source: NYS DFS HMO Rank 1,2 1 = Best 11 = Worst Total Total Prompt Pay Upheld Prompt Pay Premiums (Millions $) Prompt Pay Complaint Ratio Aetna Health Inc Atlantis Health Plan, Inc. 11 1, CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus Health Plan HIP HMO , Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans (NY), Inc , UnitedHealthcare of New York, Inc Total 3,589 2,043 1,252 7, If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a better rank. 2 HMOs with a lower complaint ratio receive a better rank. 9

11 Prompt Pay Non-profit Indemnity Health Insurance Companies 2011 Data Source: NYS DFS Non-Profit Indemnity Health Insurance Companies Rank 1,2 1 = Best 5 = Worst Total Total Prompt Pay Upheld Prompt Pay Premiums (Millions $) Prompt Pay Complaint Ratio CDPHP Universal Benefits, Inc Excellus Health Plan, Inc , Group Health Incorporated 5 2,309 1, , Healthnow New York Inc , Independent Health Benefits Corporation Total 3,006 1, , If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a better rank. 2 Health insurance companies with a lower complaint ratio receive a better rank. 10

12 Prompt Pay Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company Rank 1,2 1 = Best 38 = Worst Total Total Prompt Pay Upheld Prompt Pay Premiums (Millions $) Prompt Pay Complaint Ratio Aetna Life Insurance Company , American Family Life Assurance Company of New York American Progressive Life and Health Insurance Berkshire Life Insurance Company of America CIGNA Life Insurance Company of New York Combined Life Insurance Company of New York Connecticut General Life Insurance Company Delta Dental Insurance Company Empire HealthChoice Assurance, Inc , First Rehabilitation Life Insurance Company of America First Unum Life Insurance Company Freelancers Insurance Company, Inc Genworth Life Insurance Company of New York Guardian Life Insurance Company of America Hartford Life Insurance Company HIP Insurance Company of New York Humana Insurance Company of New York John Hancock Life & Health Insurance Company Massachusetts Mutual Life Insurance Company If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a better rank. 2 Health insurance companies with a lower complaint ratio receive a better rank. 3 Plan issues dental coverage only. 11

13 Prompt Pay Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company Rank 1,2 1 = Best 38 = Worst Total Total Prompt Pay Upheld Prompt Pay Premiums (Millions $) Prompt Pay Complaint Ratio Medco Containment Insurance Company of New York Metropolitan Life Insurance Company Mutual of Omaha Insurance Company MVP Health Insurance Company National Union Fire Insurance Company of Pittsburgh, PA New York Life Insurance Company Nippon Life Insurance Company of America Northwestern Mutual Life Insurance Company Oxford Health Insurance, Inc. 25 1, , Paul Revere Life Insurance Company Prudential Insurance Company of America Standard Life Insurance Company of New York Standard Security Life Insurance Company of New York Sterling Life Insurance Company Sun Life Insurance and Annuity Company of New York Transamerica Financial Life Insurance Company United States Life Insurance Company in the City of New York UnitedHealthcare Insurance Company of New York , Zurich American Insurance Company Total 4,310 1, , If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a better rank. 2 Health insurance companies with a lower complaint ratio receive a better rank. 12

14 Internal Appeals An internal appeal or utilization review (UR) occurs when a consumer asks a health insurance company to reconsider its refusal to pay for a medical service that the health insurance company considers experimental, investigational, not medically necessary, a clinical trial or a rare disease treatment. If you are an HMO member, you may also appeal when the HMO denies a request for out-of-network service if it offers an alternate service in-network. Health insurance companies are required to have appeals reviewed by medical professionals. Common internal appeals involve the medical necessity of hospital admissions, length of hospital stays and use of certain medical procedures. Understanding the Charts Keep in Mind Filed Internal Appeals: Number of internal appeals submitted to the health insurance company by the consumer or provider in Closed Internal Appeals: Number of internal appeals that the health insurance company decided by the end of Reversed Internal Appeals: Number of closed internal appeals that the health insurance company decided in favor of the consumer. If an internal appeal decision is reversed on appeal, the health insurance company agrees to pay for the service or procedure. Reversal Rate: Percentage of reversed internal appeals divided by closed internal appeals. Pay specific attention to a health insurance company that has a very high or very low reversal rate. Please note the following: There is no ideal reversal rate. A low reversal rate may indicate that the health insurance company makes its initial decisions correctly, so fewer decisions require reversal, but an unusually low reversal rate may indicate that the health insurance company does not give appropriate reconsideration to initial decisions. A high reversal rate may indicate that a health insurance company s internal appeal process is responsive to consumers, but an unusually high reversal rate may indicate that the health insurance company s process for making initial medical necessity decisions is flawed. The number of internal appeals filed may be higher for health insurance companies that actively promote the appeal process and encourage consumers to appeal denied services. 13

15 Internal Appeals HMOs 2011 Data Source: NYS DFS HMO Filed Internal Appeals Closed Internal Appeals 1 Reversed Internal Appeals Reversal Rate Aetna Health Inc % Atlantis Health Plan, Inc % CDPHP % Community Blue (Healthnow) % Empire HealthChoice HMO, Inc % Excellus Health Plan % HIP HMO % Independent Health Association, Inc % MVP Health Plan, Inc % Oxford Health Plans (NY), Inc. 1,443 1, % UnitedHealthcare of New York, Inc % Total 4,360 4,325 2, % 1 Closed internal appeals can exceed filed internal appeals in 2011 because closed internal appeals also include internal appeals filed prior to

16 Internal Appeals Non-profit Indemnity Health Insurance Companies 2011 Data Source: NYS DFS Non-Profit Indemnity Health Insurance Company Filed Internal Appeals Closed Internal Appeals 1 Reversed Internal Appeals Reversal Rate CDPHP Universal Benefits, Inc % Excellus Health Plan 2,583 2,598 1, % Group Health Incorporated 3,757 3,547 1, % Healthnow New York Inc % Independent Health Benefits Corporation % Total 7,261 7,037 2, % 1 Closed internal appeals can exceed filed internal appeals in 2011 because closed internal appeals also include internal appeals filed prior to

17 Internal Appeals Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company 1 Filed Internal Appeals Closed Internal Appeals 2 Reversed Internal Appeals Reversal Rate Aetna Life Insurance Company 1,399 1, % American Family Life Assurance Company of New York % American Progressive Life and Health Insurance % Berkshire Life Insurance Company of America % CIGNA Life Insurance Company of New York % Combined Life Insurance Company of New York % Connecticut General Life Insurance Company 1,818 1, % Delta Dental Insurance Company % Empire HealthChoice Assurance, Inc % First Rehabilitation Life Insurance Company of America % First Unum Life Insurance Company % Freelancers Insurance Company, Inc % Genworth Life Insurance Company of New York % Guardian Life Insurance Company of America 3,121 3,127 2, % Hartford Life Insurance Company % HIP Insurance Company of New York % Humana Insurance Company of New York % John Hancock Life & Health Insurance Company % Massachusetts Mutual Life Insurance Company % 1 Many of the commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no internal appeals. 2 Closed internal appeals can exceed filed internal appeals in 2011 because closed internal appeals also include internal appeals filed prior to

18 Internal Appeals Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company 1 Filed Internal Appeals Closed Internal Appeals 2 Reversed Internal Appeals Reversal Rate Medco Containment Insurance Company of New York % Metropolitan Life Insurance Company 12,946 12,946 11, % Mutual of Omaha Insurance Company % MVP Health Insurance Company % National Union Fire Insurance Company of Pittsburgh, PA % New York Life Insurance Company % Nippon Life Insurance Company of America % Northwestern Mutual Life Insurance Company % Oxford Health Insurance, Inc. 3,867 3,813 1, % Paul Revere Life Insurance Company % Prudential Insurance Company of America % Standard Life Insurance Company of New York % Standard Security Life Insurance Company of New York % Sterling Life Insurance Company % Sun Life Insurance and Annuity Company of New York % Transamerica Financial Life Insurance Company % United States Life Insurance Company in the City of New York % UnitedHealthcare Insurance Company of New York 56,933 56,933 25, % Zurich American Insurance Company % Total 80,410 80,467 42, % 1 Many of the commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no internal appeals. 2 Closed internal appeals can exceed filed internal appeals in 2011 because closed internal appeals also include internal appeals filed prior to

19 External Appeals After an internal appeal, consumers may request an external appeal when a health insurance company continues to deny health care services on the basis that services are experimental, investigational, not medically necessary, a clinical trial or a rare disease treatment. If you are an HMO member, you may also appeal when the HMO denies a request for out-of-network service if the HMO offers an alternate service if HMO offers an alternate service in-network. Before requesting an external appeal, you must complete the health insurance company s first-level internal appeal process or you and your health insurance company may agree jointly to waive the internal appeal process. Understanding the Charts Total External Appeals: Total number of cases assigned to an external appeal organization in Reversed External Appeals: Number of cases where an external appeal organization decided in favor of the consumer. Reversed in Part: Number of cases where an external appeal organization decided partially in favor of the consumer. For example, an HMO refused payment of a 5-day hospital stay, claiming it was not medically necessary; however, the external appeal organization decided that only 3 of the 5 days were medically necessary. Upheld External Appeals: Number of cases where an external appeal organization agreed with the health insurance company s decision not to cover a service or procedure. Reversal Rate: Percentage of reversed external appeals (cases decided in favor of the consumer) divided by total external appeals. Please note that the number of cases when an external appeal organization decided partially in favor of the consumer is also included in the reversal rate. A high reversal rate may indicate that a health insurance company does not make appropriate coverage decisions. 18

20 External Appeals HMOs 2011 Data Source: NYS DFS HMO Total External Appeals Reversed External Appeals Reversed in Part Upheld External Appeals Reversal Rate 1 Aetna Health Inc % Atlantis Health Plan, Inc % CDPHP % Community Blue (Healthnow) % Empire Healthchoice HMO Inc % Excellus Health Plan % HIP HMO % Independent Health Association, Inc % MVP Health Plan, Inc % Oxford Health Plans (NY), Inc % UnitedHealthcare of New York, Inc % Total % 1 Rate includes reversed-in-part decisions. 19

21 External Appeals Non-profit Indemnity Health Insurance Companies 2011 Data Source: NYS DFS Non-Profit Indemnity Health Insurance Company Total External Appeals Reversed External Appeals Reversed in Part Upheld External Appeals Reversal Rate 1 CDPHP Universal Benefits, Inc % Excellus Health Plan, Inc % Group Health Incorporated % Healthnow New York Inc % Independent Health Benefits Corporation % Total % 1 Rate includes reversed-in-part decisions. 20

22 External Appeals Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company 1 Total External Appeals Reversed External Appeals Reversed in Part Upheld External Appeals Reversal Rate 2 Aetna Life Insurance Company % American Family Life Assurance Company of New York % American Progressive Life and Health Insurance % Berkshire Life Insurance Company of America % CIGNA Life Insurance Company of New York % Combined Life Insurance Company of New York % Connecticut General Life Insurance Company % Delta Dental Insurance Company % Empire Healthchoice Assurance, Inc % First Rehabilitation Life Insurance Company of America % First Unum Life Insurance Company % Freelancers Insurance Company, Inc % Genworth Life Insurance Company of New York % Guardian Life Insurance Company of America % Hartford Life Insurance Company % HIP Insurance Company of New York % Humana Insurance Company of New York % John Hancock Life & Health Insurance Company % Massachusetts Mutual Life Insurance Company % 1 Many of the commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no external appeals. 2 Rate includes reversed-in-part decisions. 21

23 External Appeals Commercial Health Insurance Companies 2011 Data Source: NYS DFS Commercial Health Insurance Company 1 Total External Appeals Reversed External Appeals Reversed in Part Upheld External Appeals Reversal Rate 2 Medco Containment Insurance Company of New York % Metropolitan Life Insurance Company % Mutual of Omaha Insurance Company % MVP Health Insurance Company % National Union Fire Insurance Company of Pittsburgh, PA % New York Life Insurance Company % Nippon Life Insurance Company of America % Northwestern Mutual Life Insurance Company % Oxford Health Insurance, Inc % Paul Revere Life Insurance Company % Prudential Insurance Company of America % Standard Life Insurance Company of New York % Standard Security Life Insurance Company of New York % Sterling Life Insurance Company % Sun Life Insurance and Annuity Company of New York % Transamerica Financial Life Insurance Company % UnitedHealthcare Insurance Company of New York % United States Life Insurance Company in the City of New York % Zurich American Insurance Company % Total 1, % 1 Many of the commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no external appeals. 2 Rate includes reversed-in-part decisions. 22

24 QUALITY OF CARE AND SERVICE FOR HMOS Access and Service Data Source: NYS DOH Measure Descriptions Rating of Health Plan: The percentage of members who responded 8, 9 or 10 (on a scale of 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible) when asked, How would you rate your health plan? Getting Care Quickly: The percentage of members who responded that they usually or always : o Get appointments for regular or routine care as soon as they wanted. o Get care right away for an illness or injury. Rating of Overall Health Care: The percentage of members who responded 8, 9 or 10 (on a scale of 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible) when asked, How would you rate all your health care? Members Seen by a Provider: The percentage of adult HMO members who had an outpatient or preventive care visit within the past 3 years, as reported by the HMO. A higher score means more people in the HMO had a provider visit. Getting Needed Care: The percentage of members who responded that they usually or always thought it was easy to get: o Appointments with specialists. o Care, tests or treatments members thought they needed. 23

25 Access and Service Data Source: NYS DOH Understanding the Chart The symbols in the charts show how each HMO compares to the average for all New York HMOs. Look for HMOs with a in the chart; they performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, some plans have the same rate but a different symbol because the plan rates are based on the number of members, which can differ amongst plans, and how much a plan's rate differs from the New York average. HMO Performance Compared to the New York HMO Average Rating of Health Plan Getting Care Quickly Getting Needed Care Rating of Overall Health Care Members Seen by a Provider Ages NY HMO Average Ages Aetna Health Inc Atlantis Health Plan, Inc CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus BlueCross BlueShield Excellus (Univera Healthcare) HIP HMO Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans of NY, Inc Legend Higher than the NY HMO average Lower than the NY HMO average No symbol indicates that the average is not different from the NY HMO average. 24

26 QUALITY OF CARE AND SERVICE FOR HMOS Child and Adolescent Health Data Source: NYS DOH Measure Descriptions Childhood Immunization Status: The percentage of two-year olds who were fully immunized. Fully immunized means the twoyear olds received the following vaccines 4 Diphtheria/ Tetanus/ Pertussis, 3 Polio, 1 Measles/Mumps/Rubella, 2 H Influenza type B, 3 Hepatitis B, 1 Varicella and 4 pneumococcal. This measure was not collected for 2010; 2009 data is presented. Well-Child Visit in the First 15 Months of Life: The percentage of children who had five or more well-child and preventive health visits in their first 15 months of life. Adolescent Well-Care Visits: The percentage of adolescents (ages 12-21) who had at least one well-care or preventive visit during the measurement year. Child Weight Assessment: The percentage of members, ages 3 to 17 years, who had a visit with a health care provider and whose weight was assessed by plotting the member s BMI on a growth chart to determine a BMI percentile ranking. Well-Child Visit During the 3 rd, 4 th, 5 th and 6 th Years: The percentage of children between the ages of three and six years who had a well-child and preventive health visits in the past year. 25

27 Child and Adolescent Health Data Source: NYS DOH Understanding the Chart The symbols in the charts show how each HMO compares to the average for all New York HMOs. Look for HMOs with a in the chart; they performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, some plans have the same rate but a different symbol because the plan rates are based on the number of members, which can differ amongst plans, and how much a plan's rate differs from the New York average. Legend Higher than the NY HMO average Lower than the NY HMO average HMO Performance Compared to the New York HMO Average Childhood Immunization Status** Well-Child Visits in the First 15 Months of Life Well-Child Visits During the 3 rd, 4 th, 5 th and 6 th Years Adolescent Well-Care Visits Child Weight Assessment NY HMO Average Aetna Health Inc Atlantis Health Plan, Inc CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus BlueCross BlueShield Excellus (Univera Healthcare) HIP HMO Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans of NY, Inc No symbol indicates that the average is not different from the NY HMO average. ** Rotated measure. Data is from

28 QUALITY OF CARE AND SERVICE FOR HMOS Adult Health Data Source: NYS DOH Measure Descriptions Cervical Cancer Screening: The percentage of women, ages 24 to 64 years, who had a Pap test within the measurement year or the two years prior. Colorectal Cancer Screening: The percentage of adults, ages 50 to 75 years, who had appropriate screening for colorectal cancer. This measure was not collected for 2010; 2009 data is presented. Adult BMI Assessment: The percentage of adults, ages 18 to 74 years, who had their body mass index BMI measured by their health care provider within the past two years. Controlling High Blood Pressure: The percentage of members, ages 18 to 85 years, who have hypertension and whose blood pressure is below 140/90. Cholesterol Management After Cardiovascular Event Level Controlled: The percentage of members, ages 18 to 75 years, with a cardiovascular condition, whose cholesterol level LDL-C results was <100 mg/dl. This measure was not collected for 2010; 2009 data is presented. 27

29 Adult Health Data Source: NYS DOH Understanding the Chart The symbols in the charts show how each HMO compares to the average for all New York HMOs. Look for HMOs with a in the chart; they performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, some plans have the same rate but a different symbol because the plan rates are based on the number of members, which can differ amongst plans, and how much a plan's rate differs from the New York average. HMO Performance Compared to the New York HMO Average Cervical Cancer Screening Colorectal Cancer Screening** Adult BMI Assessment Controlling High Blood Pressure Cholesterol Management - Controlled (<100 mg/dl)** NY HMO Average Aetna Health Inc Atlantis Health Plan, Inc CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus BlueCross BlueShield Excellus (Univera Healthcare) HIP HMO Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans of NY, Inc Legend Higher than the NY HMO average Lower than the NY HMO average No symbol indicates that the average is not different from the NY HMO average. ** Rotated measure. Data is from

30 QUALITY OF CARE AND SERVICE FOR HMOS Diabetes Data Source: NYS DOH This section reports on components of care for members with diabetes and the rate at which they received necessary components of diabetes care. Measures presented are grouped into those that monitor diabetes and those that measure outcomes for diabetes. This measure was not collected for 2010; 2009 data is presented. Measure Descriptions Dilated Eye Exam: The percentage of members with diabetes who had a retinal eye screening exam over the last two years. Nephropathy Monitoring: The percentage of members with diabetes who were screened or were monitored for kidney damage. Lipids Controlled: The percentage of members with diabetes whose level of bad cholesterol was in control (LDL-C <100 mg/dl). Blood Pressure Controlled: The percentage of members with diabetes whose blood pressure is below 140/90. Poor HbA1c Control: The percentage of members with diabetes whose most recent HbA1c level indicated poor control (HbA1c result >9.0 percent, no HbA1c test, or missing HbA1c test result). A low rate is desirable for this measure. 29

31 Diabetes Data Source: NYS DOH Understanding the Chart The symbols in the charts show how each HMO compares to the average for all New York HMOs. Look for HMOs with a in the chart; they performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, some plans have the same rate but a different symbol because the plan rates are based on the number of members, which can differ amongst plans, and how much a plan's rate differs from the New York average. Legend Higher than the NY HMO average Lower than the NY HMO average HMO Performance Compared to the New York HMO Average Dilated Eye Exam** Nephropathy Monitoring** Poor HbA1c Control** Lipids Controlled (<100 mg/dl)** Blood Pressure Controlled (<140/90 mm Hg)** NY HMO Average Aetna Health Inc Atlantis Health Plan, Inc CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus BlueCross BlueShield Excellus (Univera Healthcare) HIP HMO Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans of NY, Inc No symbol indicates that the average is not different from the NY HMO average. ** Rotated measure. Data is from For Poor HBA1c Control, a low rate is desirable. 30

32 QUALITY OF CARE AND SERVICE FOR HMOS Behavioral Health Data Source: NYS DOH Measure Descriptions Follow-Up Care for Children Prescribed ADHD Medication - Initiation Phase: The percentage of children, ages 6 to 12 years, with a new prescription for ADHD mediation and who had one follow-up visit with a practitioner within the 30 days after starting the medication. Follow-up After Hospitalization for Mental Illness: This measure is for members ages 6 years and older who were hospitalized for treatment of selected mental health disorders (such as depression or bipolar disorder) and has two time-frame components. Antidepressant Medication Management: This measure is for members ages 18 years and older who were diagnosed with depression and treated with an antidepressant medication and has two components of care. o Within 7 Days: The percentage of members who were hospitalized for treatment for selected mental health disorders and were seen by a mental health provider within 7 days after discharge. o o Effective Acute Phase Treatment: The percentage of members who remained on antidepressant medication during the entire 12-week acute treatment phase. Effective Continuation Phase Treatment: The percentage of members who remained on antidepressant medication for at least six months. o Within 30 Days: The percentage of members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 30 days of discharge. 31

33 Behavior Health Data Source: NYS DOH Understanding the Chart The symbols in the charts show how each HMO compares to the average for all New York HMOs. Look for HMOs with a in the chart; they performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, some plans have the same rate but a different symbol because the plan rates are based on the number of members, which can differ amongst plans, and how much a plan's rate differs from the New York average. Legend Higher than the NY HMO average Lower than the NY HMO average HMO Performance Compared to the New York HMO Average Follow-Up Care for Children Prescribed ADHD Medication Initiation Phase Antidepressant Medication Management Effective Acute Phase Effective Continuation Phase Follow-Up After Hospitalization for Mental Illness Within 7 Days Within 30 Days NY HMO Average Aetna Health Inc Atlantis Health Plan, Inc CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus BlueCross BlueShield Excellus (Univera Healthcare) HIP HMO Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans of NY, Inc No symbol indicates that the average is not different from the NY HMO average. Sample size too small to report. 32

34 QUALITY OF CARE AND SERVICE FOR HMOS Quality of Providers Data Source: NYS DOH Measure Descriptions Satisfaction with Personal Doctor: The percentage of members who responded 8, 9 or 10 (on a scale of 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible) when asked, How would you rate your personal doctor? Satisfaction with Specialist: The percentage of members who responded 8, 9 or 10 (on a scale of 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible) when asked How would you rate your specialist? Doctors who are Certified by a Medical Board: The percentage of internal medicine doctors, OB/GYNs and pediatricians who are board certified. A higher percentage means the HMO has more board-certified doctors in the practice areas listed. To be board certified, doctors must receive additional training and pass an exam in their specialty. While board certification is not a guarantee of quality, it shows that a doctor has knowledge that the specialty board considers necessary. Satisfaction with Provider Communication: The percentage of members who responded that their doctors or health care providers usually or always : o o o o Listen carefully to them. Explain things in a way they understand. Show respect for what they have to say. Spend enough time with them during visits. 33

35 Quality of Providers Data Source: NYS DOH Understanding the Chart The symbols in the charts show how each HMO compares to the average for all New York HMOs. Look for HMOs with a in the chart; they performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, some plans have the same rate but a different symbol because the plan rates are based on the number of members, which can differ amongst plans, and how much a plan's rate differs from the New York average. Legend Higher than the NY HMO average Lower than the NY HMO average HMO Performance Compared to the New York HMO Average Satisfaction with Personal Doctor Satisfaction with Specialist Satisfaction with Provider Communication Doctors who are Certified by a Medical Board Internal Medicine OB/GYN Pediatric NY HMO Average Aetna Health Inc Atlantis Health Plan, Inc NV NV NV CDPHP Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus BlueCross BlueShield Excellus (Univera Healthcare) HIP HMO Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans of NY, Inc No symbol indicates that the average is not different from the NY HMO average. NV Plan submitted invalid data. 34

36 QUALITY OF CARE AND SERVICE FOR HMOS Grievances 2011 Data Source: NYS DFS A grievance is when a consumer complains to a health insurance company about a denial based on limitations or exclusions in the contract. Medical necessity issues are internal appeals, not grievances. Common grievances include trouble getting referrals to specialists and disagreements over benefit coverage. According to New York State law, HMOs must have a system in place for responding to members concerns. An internal HMO Committee reviews grievances and decides whether to reverse or uphold a denial. Understanding the Chart Keep in Mind: Filed Grievances: Number of grievances submitted to the HMO. Closed Grievances: Number of grievances the HMO resolved by the end of Upheld Grievances: Number of closed grievances where the HMO stood by its original decision and did not decide in favor of the member or provider. Reversed Grievances: Number of closed grievances where the HMO changed its initial decision and decided in favor of the member or provider. Reversal Rate: Percentage of Reversed Grievances (closed grievances decided in favor of the member or provided) divided by closed grievances. Pay specific attention to a health insurance company that has a very high or very low reversal rate. Please note the following: There is no ideal reversal rate. A low reversal rate may indicate that the health insurance company makes its initial decisions correctly, so fewer decisions require reversal, but an unusually low reversal rate may indicate that the health insurance company does not give appropriate reconsideration to initial decisions. A high reversal rate may indicate that a health insurance company s grievance process is responsive to consumers, but an unusually high reversal rate may indicate that the health insurance company s process for making initial decisions is flawed. The number of grievances filed may be higher for health insurance companies that actively promote the grievance process to consumers. 35

37 Grievances 2011 Data Source: NYS DFS HMO Filed Grievances Closed Grievances 1 Reversed Grievances Upheld Grievances Reversal Rate Aetna Health Inc % Atlantis Health Plan, Inc % CDPHP % Community Blue (Healthnow) % Empire HealthChoice HMO, Inc % Excellus Health Plan² % HIP HMO % Independent Health Benefits Corp² % MVP Health Plan, Inc % Oxford Health Insurance, Inc.³ 7,896 4,926 2,284 5, % UnitedHealthcare of New York, Inc % Total 11,980 8,988 4,017 7, % 1 Closed grievances can exceed filed grievances in 2011 because closed grievances also include grievances filed prior to Includes grievances for the non-profit company. 3 Includes grievances for commercial company contracts. 36

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