Comparing Texas HMOs 2014

Transcription

1 Comparing Texas HMOs 2014 Health Plan Quality From the Consumer s Point of View All Regions Included: Central Texas East Texas Gulf Coast Texas North Texas Panhandle/Plains Texas South Texas West Texas Prepared by the OFFICE OF PUBLIC INSURANCE COUNSEL Deeia Beck, Public Counsel

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3 Comparing Texas HMOs Table of Contents SECTION 1: BACKGROUND About the Report Choosing an HMO Your Rights as a Consumer Types of Health Plans 2 SECTION 2: CAHPS 5.0H 1 SURVEY RESULTS Central Texas Plans East Texas Plans Gulf Coast Texas Plans North Texas Plans Panhandle/Plains Texas Plans South Texas Plans West Texas Plans 7 SECTION 3: COMPLAINTS AGAINST HMOS AND APPEALS HMO Complaint Data Denials, Appeals, and Independent Review Organizations 107 SECTION 4: ADDITIONAL INFORMATION About the Survey HMO Market Share Data HMO Financial Information Plans Available Through the Federal Marketplace Additional Sources of Information HMO Customer Service Contact Information The CAHPS 5.0H Survey is a part of the Healthcare Effectiveness Data and Information Set (HEDIS), which is compiled by the National Committee for Quality Assurance (NCQA). NCQA is a non-profit organization dedicated to improving healthcare quality. The CAHPS 5.0H Surveys are designed to capture accurate and reliable information from consumers about their experience with healthcare. More information about the survey is provided on pages 2 and 114.

4 About the Report The Office of Public Insurance Counsel (OPIC) is an independent state agency that advocates on behalf of insurance consumers as a class in the state of Texas. In 1997, the 75 th Texas Legislature directed OPIC to issue annual reports comparing Health Maintenance Organizations (HMOs) in the state of Texas. Comparing Texas HMOs 2014 reflects the experience of Texans enrolled in HMOs during Section One of the report offers background information on the report, information on consumer rights, and information on types of health plans. Section Two provides the results of the Consumer Assessment of Healthcare Providers and Systems, Version 5.0H (CAHPS 5.0H), by service area. Section Three contains information on HMO complaints, appeals, and independent review organizations. Section Four provides HMO market share data and financial information, HMO customer service contact information, additional sources of healthcare information, and information on the survey. About the Survey The CAHPS 5.0H survey was performed by independent vendors certified by the National Committee for Quality Assurance (NCQA), a private, non-profit organization. The survey comprises the consumer satisfaction measure for the Healthcare Effectiveness Data and Information Set (HEDIS ). Texas law requires HMOs to submit HEDIS measures including consumer satisfaction data on an annual basis. The survey data was compiled from answers from 5,694 adults enrolled in commercial health plans across the state of Texas. The surveyors mailed questionnaires to approximately 24,600 plan members eligible to participate and followed up by telephone with those who did not respond. Participants answered questions about their satisfaction with the healthcare services they received in the previous twelve months. The report does not include data for Medicare, Medicaid, or Employee Retirement Income Security Act of 1974 (ERISA) plans. ERISA plans include government and self-funded plans. Pages contain contact information regarding Medicare, Medicaid, and ERISA plans. About HMOs Health Maintenance Organizations (HMOs) are managed care plans that provide healthcare services to members through networks of doctors, hospitals, and other healthcare providers. An HMO member must select a primary care physician who oversees medical care and provides referrals to specialists. HMOs require members to pay a set copayment for covered services within the network. The table on page 5 provides more information on HMOs and compares HMOs to other types of health plans. How to Use the Report Choosing an HMO can feel overwhelming. When you select an HMO, you are not only choosing health plan benefits, but also the network of doctors, hospitals, and other providers who deliver your care as well as the administrators who review and approve recommended care. You can obtain information on service area, benefits, cost, and available providers directly from the HMOs. However, consumer satisfaction information can be difficult to find. Comparing Texas HMOs 2014 provides this information for you. Office of Public Insurance Counsel Comparing Texas HMOs

5 Choosing an HMO When you choose an HMO, you will want to make an apples-to-apples comparison of the plans. This section lists a few points of comparison to consider. This is not an exhaustive list, but it is intended to help you break down a complicated decision into smaller pieces. You may use the table below to take notes on the HMOs you consider. Service-Area Availability HMOs cover specific service areas. Review the HMOs membership information to find one with a service area close to where you live or work. Benefits Individuals utilize different services based on medical conditions, age, and family needs. Review HMO benefit information for coverage of medications or services that you use. You may need to contact the plans to get all your questions answered. Affordability Your overall healthcare costs will include your premiums as well as other out-of-pocket costs. To compare affordability, estimate your annual healthcare needs and calculate the total out-of-pocket cost you would pay with each HMO. Provider Availability Some consumers find it important to receive care from specific doctors or hospitals. Review provider directories for information on in-network providers. Consumer Satisfaction The survey data in this report provide an aggregate look at consumer satisfaction for members currently enrolled in HMOs. Review the information in this report to find out how current plan enrollees rate the plan quality of the HMOs you are considering. HMO Service Area Availability Benefits Affordability Provider Availability Consumer Satisfaction Office of Public Insurance Counsel Comparing Texas HMOs

6 Your Rights as a Consumer An HMO must provide requested information regarding the terms and conditions of the plan including: covered services exclusions and limitations prior authorization requirements continuity of treatment approved prescription drugs complaint resolution the HMO s toll-free telephone number You have the right to certain consumer protections under federal and state law. Under Federal Law: Health plans must provide a required set of preventive services to enrollees, waiving applicable innetwork deductibles, copays, and coinsurance. Health plans may not require referrals for in-network pediatric and OB-GYN care. Health plans may not require prior approval for emergency care. Health plans that offer dependent coverage must allow adult children who lack access to employersponsored coverage the option of remaining on a parent s plan up to age 26. Health plans may not deny coverage or apply pre-existing condition exclusions to coverage. Health plans may not impose lifetime dollar limits. Health plans may not rescind health insurance coverage. Consumers have a right to internal and external appeals of claim and coverage denials. Under Texas State Law: Health plans must provide access to specialist care and prescription drugs. Health plans must provide access to regular physical examinations. Health plans must provide emergency care, including care at out-of-network hospitals. Health plans must provide continuity of care when your doctor leaves the network. Health plans must provide a procedure for complaints, appeals, and independent review of adverse determinations. Health plans may not provide financial rewards to doctors for withholding necessary care. Health plans must allow members to change primary care physicians at least four times per year. Health plans may not prohibit doctors from discussing treatment options with patients. Health plans must provide covered healthcare services within a certain distance of a consumer s home. Consumers have the right to request mediation for certain out-of-network claims. Consumers may take legal action against a non-erisa HMO plan for harm caused by its treatment decisions. Providers may not bill patients for covered services if the HMO fails to pay. Hospitals and doctors must provide an itemized statement of billed services and/or an estimate of charges upon request. The Texas Department of Insurance publishes a brochure describing your rights entitled Health Maintenance Organizations. You may access this document on TDI s website at or by calling to request a copy. Office of Public Insurance Counsel 4 Comparing Texas HMOs 2014

7 Types of Health Plans HMO Health Maintenance Organization PPO Preferred Provider Organization EPO Exclusive Provider Organization HMO/POS Health Maintenance Organization with Point-of-Service Option Traditional Insurance Fee-for-Service Closed Open Closed Open No Network Type of Network You must use innetwork doctors, hospitals, and specialists. You may use innetwork doctors, hospitals, and specialists or go outside the network. You must use innetwork doctors, hospitals, and specialists. You may use innetwork doctors, hospitals, and specialists or go outside the network. You may use any doctor, hospital, or specialist you choose. Limits on your choice of doctors HMO plans typically require you to choose a primary care physician (PCP) from the HMO s network. With some exceptions, you must obtain a referral from your PCP before seeing other doctors in the network. Many PPOs permit you to see any doctor in the network without a referral. However, some PPOs do require you to choose a PCP and obtain a referral before seeing other doctors in the PPO s network. Verify referral requirements with the PPO before making an appointment. EPOs typically permit you to see any network provider without a referral. Verify referral requirements with the EPO before making an appointment. An HMO/POS will typically require you to choose a PCP and obtain a referral from that doctor before making an appointment with other doctors in the network. No limitations. Incentives to use network doctors Except in an emergency, an HMO will not cover services provided by out-ofnetwork providers. The PPO will typically reimburse a higher percentage of the cost of your healthcare services if you use in-network providers. Except in limited circumstances (such as an emergency), an EPO will not cover services provided by out-ofnetwork providers. An HMO/POS will typically reimburse a higher percentage of the cost of your healthcare services if you use in-network providers. Not applicable. Payment for services When you access the HMO network, you will pay designated copays for covered services. Typically, you will not pay a deductible or coinsurance. An in-network provider cannot bill you for any remaining balance after you meet your copay. When you access the PPO network, you typically pay a copay for covered services. You may also pay a percentage of the overall cost of the service. When you use an out-of-network provider, you will be responsible for your deductible, coinsurance, and any remaining balance charged by the healthcare provider. When you access the EPO network, you may pay copays, coinsurance, or deductibles for covered services. When you use an out-of-network provider, you will typically pay the entire cost of the service. When you access the HMO network, you will pay designated copays. When you use an out-of-network provider, you will be responsible for your deductible, coinsurance, and any remaining balance charged by the healthcare provider. Fee-for-Service insurance plans partially pay for the medical services you receive. You will be responsible for coinsurance plus any remaining balance charged by the healthcare provider. Office of Public Insurance Counsel 5 Comparing Texas HMOs 2014

8 Office of Public Insurance Counsel 6 Comparing Texas HMOs 2014

9 Section 2: Survey Results Office of Public Insurance Counsel 7 Comparing Texas HMOs 2014

10 Office of Public Insurance Counsel 8 Comparing Texas HMOs 2014

11 for Central Texas Plans The counties included in the Central Texas area are: Bastrop Burnet Grimes Leon Mills Bell Caldwell Hamilton Limestone Robertson Blanco Coryell Hays Llano San Saba Bosque Falls Hill Madison Travis Brazos Fayette Lampasas McLennan Washington Burleson Freestone Lee Milam Williamson This section features survey results for plans that serve the Central Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers with greater access to data to compare HMOs. Office of Public Insurance Counsel 9 Comparing Texas HMOs 2014 Central Texas

12 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% Aetna Health, Inc. (Austin) 20% 39% 41% Aetna Health, Inc. (Dallas/Fort Worth) 17% 36% 47% Aetna Health, Inc. (Houston) 18% 39% 42% CIGNA HealthCare of Texas, Inc. (South Texas) 21% 35% 44% FIRSTCARE (Waco) 26% 45% 29% HMO Blue Texas (Dallas/Fort Worth) 10% 33% 56% 12% 38% 50% HMO Blue Texas (Houston) 16% 32% 52% Humana Health Plan of Texas (Austin) 17% 38% 45% Humana Health Plan of Texas (Houston) 22% 31% 47% Humana Health Plan of Texas (San Antonio) 18% 29% 53% Scott and White Health Plan (Central Texas) 23% 32% 44% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 29% 40% 31% Office of Public Insurance Counsel 10 Comparing Texas HMOs 2014 Central Texas

13 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% Aetna Health, Inc. (Austin) Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Austin) 12% 13% 8% 14% 16% 9% 11% 14% 11% 38% 32% 44% 32% 38% 37% 32% 34% 41% 50% 54% 48% 54% 46% 55% 57% 52% 49% - Central Texas Humana Health Plan of Texas (Houston) 14% 35% 52% Humana Health Plan of Texas (San Antonio) 12% 33% 55% Scott and White Health Plan (Central Texas) 11% 34% 55% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 11% 36% 53% Office of Public Insurance Counsel 11 Comparing Texas HMOs 2014 Central Texas

14 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% Aetna Health, Inc. (Austin) 5 32% 63% Aetna Health, Inc. (Dallas/Fort Worth) 6% 24% 70% Aetna Health, Inc. (Houston) 10% 27% 63% CIGNA HealthCare of Texas, Inc. (South Texas) 11% 22% 67% FIRSTCARE (Waco) 7% 23% 70% HMO Blue Texas (Dallas/Fort Worth) 9% 28% 64% 10% 23% 67% HMO Blue Texas (Houston) 11% 25% 64% Humana Health Plan of Texas (Austin) 9% 19% 72% Humana Health Plan of Texas (Houston) 6% 21% 73% Humana Health Plan of Texas (San Antonio) 8% 20% 72% Scott and White Health Plan (Central Texas) 9% 24% 67% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 10% 24% 67% Office of Public Insurance Counsel 12 Comparing Texas HMOs 2014 Central Texas

15 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% Aetna Health, Inc. (Austin) Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Austin) 6% 29% 9% 24% 9% 24% 12% 25% 14% 31% 8% 19% 8% 22% 6% 28% 6% 16% 65% 67% 68% 63% 55% 73% 70% 66% 79% - Central Texas Humana Health Plan of Texas (Houston) 2 26% 72% Humana Health Plan of Texas (San Antonio) 11% 16% 73% Scott and White Health Plan (Central Texas) 8% 16% 76% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 13% 24% 63% Office of Public Insurance Counsel 13 Comparing Texas HMOs 2014 Central Texas

16 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests, or treatment they needed through their health plan. 13% 30% 56% Aetna Health, Inc. (Austin) 10% 31% 60% Aetna Health, Inc. (Dallas/Fort Worth) 11% 24% 65% Aetna Health, Inc. (Houston) 13% 28% 59% CIGNA HealthCare of Texas, Inc. (South Texas) 13% 32% 55% FIRSTCARE (Waco) 11% 35% 54% HMO Blue Texas (Dallas/Fort Worth) 12% 31% 57% 14% 32% 54% HMO Blue Texas (Houston) 14% 36% 51% Humana Health Plan of Texas (Austin) 8% 33% 59% Humana Health Plan of Texas (Houston) 14% 33% 52% Humana Health Plan of Texas (San Antonio) 18% 27% 55% Scott and White Health Plan (Central Texas) 16% 29% 55% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 16% 26% 58% Office of Public Insurance Counsel 14 Comparing Texas HMOs 2014 Central Texas

17 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% Aetna Health, Inc. (Austin) Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Austin) 15% 10% 16% 17% 14% 13% 12% 20% 16% 22% 25% 22% 22% 30% 23% 27% 24% 24% 63% 64% 62% 61% 56% 64% 61% 56% 59% - Central Texas Humana Health Plan of Texas (Houston) 19% 23% 57% Humana Health Plan of Texas (San Antonio) 23% 27% 50% Scott and White Health Plan (Central Texas) 16% 27% 57% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 18% 28% 53% Office of Public Insurance Counsel 15 Comparing Texas HMOs 2014 Central Texas

18 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% Aetna Health, Inc. (Austin) 4 15% 81% Aetna Health, Inc. (Dallas/Fort Worth) 4 22% 74% Aetna Health, Inc. (Houston) 6% 18% 76% CIGNA HealthCare of Texas, Inc. (South Texas) 6% 16% 78% FIRSTCARE (Waco) 5 17% 78% HMO Blue Texas (Dallas/Fort Worth) 5 22% 73% 6% 20% 74% HMO Blue Texas (Houston) 9% 18% 73% Humana Health Plan of Texas (Austin) 6% 18% 76% Humana Health Plan of Texas (Houston) 6% 21% 73% Humana Health Plan of Texas (San Antonio) 6% 18% 76% Scott and White Health Plan (Central Texas) 4 20% 77% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 5 15% 80% Office of Public Insurance Counsel 16 Comparing Texas HMOs 2014 Central Texas

19 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% Aetna Health, Inc. (Austin) Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Austin) 7% 14% 12% 10% 12% 9% 13% 21% 14% 31% 34% 34% 35% 38% 34% 35% 28% 33% 62% 52% 54% 56% 50% 57% 52% 51% 53% - Central Texas Humana Health Plan of Texas (Houston) 10% 33% 57% Humana Health Plan of Texas (San Antonio) 10% 29% 61% Scott and White Health Plan (Central Texas) 23% 33% 45% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 13% 37% 50% Office of Public Insurance Counsel 17 Comparing Texas HMOs 2014 Central Texas

20 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% Aetna Health, Inc. (Austin) 12% 26% 62% Aetna Health, Inc. (Dallas/Fort Worth) 15% 31% 55% Aetna Health, Inc. (Houston) 14% 19% 68% CIGNA HealthCare of Texas, Inc. (South Texas) 9% 21% 69% FIRSTCARE (Waco) 10% 23% 67% HMO Blue Texas (Dallas/Fort Worth) 12% 19% 68% 16% 26% 59% HMO Blue Texas (Houston) 9% 26% 64% Humana Health Plan of Texas (Austin) 17% 21% 62% Humana Health Plan of Texas (Houston) 10% 26% 64% Humana Health Plan of Texas (San Antonio) 17% 19% 65% Scott and White Health Plan (Central Texas) 17% 18% 65% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 25% 28% 48% Office of Public Insurance Counsel 18 Comparing Texas HMOs 2014 Central Texas

21 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% Aetna Health, Inc. (Austin) Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Austin) 34% 36% 38% 38% 48% 33% 34% 34% 40% 37% 34% 32% 37% 30% 21% 37% 26% 29% 29% 30% 30% 25% 23% 46% 29% 40% 31% - Central Texas Humana Health Plan of Texas (Houston) 50% 27% 22% Humana Health Plan of Texas (San Antonio) 38% 31% 31% Scott and White Health Plan (Central Texas) 45% 31% 24% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 43% 29% 27% Office of Public Insurance Counsel 19 Comparing Texas HMOs 2014 Central Texas

22 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reasons you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% Aetna Health, Inc. (Austin) 13% 10% 28% 48% Aetna Health, Inc. (Dallas/Fort Worth) 19% 12% 26% 43% Aetna Health, Inc. (Houston) 19% 11% 28% 42% CIGNA HealthCare of Texas, Inc. (South Texas) 19% 12% 26% 43% FIRSTCARE (Waco) 14% 11% 25% 50% HMO Blue Texas (Dallas/Fort Worth) 17% 12% 26% 46% 14% 9% 27% 51% HMO Blue Texas (Houston) 17% 11% 25% 47% Humana Health Plan of Texas (Austin) 18% 15% 19% 48% Humana Health Plan of Texas (Houston) 23% 10% 26% 40% Humana Health Plan of Texas (San Antonio) 15% 11% 25% 49% Scott and White Health Plan (Central Texas) 18% 10% 25% 47% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 15% 7% 30% 48% Office of Public Insurance Counsel 20 Comparing Texas HMOs 2014 Central Texas

23 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 21 Comparing Texas HMOs 2014 Central Texas

24 Office of Public Insurance Counsel 22 Comparing Texas HMOs 2014 Central Texas

25 for East Texas Plans The counties included in the East Texas area are: Anderson Delta Hopkins Morris Rains Shelby Van Zandt Angelina Franklin Houston Nacogdoches Red River Smith Wood Bowie Gregg Jasper Newton Rusk Titus Camp Hardin Jefferson Orange Sabine Trinity Cass Harrison Lamar Panola San Augustine Tyler Cherokee Henderson Marion Polk San Jacinto Upshur This section features survey results for plans that serve the East Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers with greater access to data to compare HMOs. Office of Public Insurance Counsel 23 Comparing Texas HMOs 2014 East Texas

26 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% Aetna Health, Inc. (Dallas/Fort Worth) 17% 36% 47% Aetna Health, Inc. (Houston) 18% 39% 42% CIGNA HealthCare of Texas, Inc. (South Texas) 21% 35% 44% FIRSTCARE (Waco) 26% 45% 29% HMO Blue Texas (Dallas/Fort Worth) 10% 33% 56% 12% 38% 50% HMO Blue Texas (Houston) 16% 32% 52% Humana Health Plan of Texas (Houston) 22% 31% 47% Office of Public Insurance Counsel 24 Comparing Texas HMOs 2014 East Texas

27 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Houston) 13% 32% 54% 8% 44% 48% 14% 32% 54% 16% 38% 46% 9% 37% 55% 11% 32% 57% 14% 34% 52% 14% 35% 52% - East Texas Office of Public Insurance Counsel 25 Comparing Texas HMOs 2014 East Texas

28 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% Aetna Health, Inc. (Dallas/Fort Worth) 6% 24% 70% Aetna Health, Inc. (Houston) 10% 27% 63% CIGNA HealthCare of Texas, Inc. (South Texas) 11% 22% 67% FIRSTCARE (Waco) 7% 23% 70% HMO Blue Texas (Dallas/Fort Worth) 9% 28% 64% 10% 23% 67% HMO Blue Texas (Houston) 11% 25% 64% Humana Health Plan of Texas (Houston) 6% 21% 73% Office of Public Insurance Counsel 26 Comparing Texas HMOs 2014 East Texas

29 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Houston) 9% 24% 9% 24% 12% 25% 14% 31% 8% 19% 8% 22% 6% 28% 2 26% 67% 68% 63% 55% 73% 70% 66% 72% - East Texas Office of Public Insurance Counsel 27 Comparing Texas HMOs 2014 East Texas

30 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests or treatment they needed through their health plan. 13% 30% 56% Aetna Health, Inc. (Dallas/Fort Worth) 11% 24% 65% Aetna Health, Inc. (Houston) 13% 28% 59% CIGNA HealthCare of Texas, Inc. (South Texas) 13% 32% 55% FIRSTCARE (Waco) 11% 35% 54% HMO Blue Texas (Dallas/Fort Worth) 12% 31% 57% 14% 32% 54% HMO Blue Texas (Houston) 14% 36% 51% Humana Health Plan of Texas (Houston) 14% 33% 52% Office of Public Insurance Counsel 28 Comparing Texas HMOs 2014 East Texas

31 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Houston) 10% 25% 64% 16% 22% 62% 17% 22% 61% 14% 30% 56% 13% 23% 64% 12% 27% 61% 20% 24% 56% 19% 23% 57% - East Texas Office of Public Insurance Counsel 29 Comparing Texas HMOs 2014 East Texas

32 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% Aetna Health, Inc. (Dallas/Fort Worth) 4 22% 74% Aetna Health, Inc. (Houston) 6% 18% 76% CIGNA HealthCare of Texas, Inc. (South Texas) 6% 16% 78% FIRSTCARE (Waco) 5 17% 78% HMO Blue Texas (Dallas/Fort Worth) 5 22% 73% 6% 20% 74% HMO Blue Texas (Houston) 9% 18% 73% Humana Health Plan of Texas (Houston) 6% 21% 73% Office of Public Insurance Counsel 30 Comparing Texas HMOs 2014 East Texas

33 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Houston) 14% 34% 52% 12% 34% 54% 10% 35% 56% 12% 38% 50% 9% 34% 57% 13% 35% 52% 21% 28% 51% 10% 33% 57% - East Texas Office of Public Insurance Counsel 31 Comparing Texas HMOs 2014 East Texas

34 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% Aetna Health, Inc. (Dallas/Fort Worth) 15% 31% 55% Aetna Health, Inc. (Houston) 14% 19% 68% CIGNA HealthCare of Texas, Inc. (South Texas) 9% 21% 69% FIRSTCARE (Waco) 10% 23% 67% HMO Blue Texas (Dallas/Fort Worth) 12% 19% 68% 16% 26% 59% HMO Blue Texas (Houston) 9% 26% 64% Humana Health Plan of Texas (Houston) 10% 26% 64% Office of Public Insurance Counsel 32 Comparing Texas HMOs 2014 East Texas

35 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% Aetna Health, Inc. (Dallas/Fort Worth) Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) HMO Blue Texas (Houston) Humana Health Plan of Texas (Houston) 36% 34% 30% 38% 32% 30% 38% 37% 25% 48% 30% 23% 33% 21% 46% 34% 37% 29% 34% 26% 40% 50% 27% 22% - East Texas Office of Public Insurance Counsel 33 Comparing Texas HMOs 2014 East Texas

36 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reasons you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% Aetna Health, Inc. (Dallas/Fort Worth) 19% 12% 26% 43% Aetna Health, Inc. (Houston) 19% 11% 28% 42% CIGNA HealthCare of Texas, Inc. (South Texas) 19% 12% 26% 43% FIRSTCARE (Waco) 14% 11% 25% 50% HMO Blue Texas (Dallas/Fort Worth) 17% 12% 26% 46% HMO Blue Texas (Houston) 14% 9% 27% 51% Humana Health Plan of Texas (Houston) 17% 11% 25% 47% 23% 10% 26% 40% Office of Public Insurance Counsel 34 Comparing Texas HMOs 2014 East Texas

37 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 35 Comparing Texas HMOs 2014 East Texas

38 Office of Public Insurance Counsel 36 Comparing Texas HMOs 2014 East Texas

39 for Gulf Coast Texas Plans The counties included in the Gulf Coast Texas area are: Austin Galveston Walker Brazoria Harris Waller Chambers Liberty Wharton Colorado Matagorda Fort Bend Montgomery This section features survey results for plans that serve the Gulf Coast Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers with greater access to data to compare HMOs. Office of Public Insurance Counsel 37 Comparing Texas HMOs 2014 Gulf Coast Texas

40 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% Aetna Health, Inc. (Houston) 18% 39% 42% CIGNA HealthCare of Texas, Inc. (South Texas) 21% 35% 44% FIRSTCARE (Waco) 26% 45% 29% 12% 38% 50% HMO Blue Texas (Houston) 16% 32% 52% Humana Health Plan of Houston (Houston) 22% 31% 47% Scott and White Health Plan (Central Texas) 23% 32% 44% United Healthcare of Texas, Inc. (Houston/San Antonio) 19% 33% 49% Office of Public Insurance Counsel 38 Comparing Texas HMOs 2014 Gulf Coast Texas

41 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Houston) Humana Health Plan of Houston (Houston) Scott and White Health Plan (Central Texas) United Healthcare of Texas, Inc. (Houston/San Antonio) 8% 44% 14% 32% 16% 38% 11% 32% 14% 34% 14% 35% 11% 34% 17% 28% 48% 54% 46% 57% 52% 52% 55% 55% - Gulf Coast Texas Office of Public Insurance Counsel 39 Comparing Texas HMOs 2014 Gulf Coast Texas

42 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% Aetna Health, Inc. (Houston) 10% 27% 63% CIGNA HealthCare of Texas, Inc. (South Texas) 11% 22% 67% FIRSTCARE (Waco) 7% 23% 70% 10% 23% 67% HMO Blue Texas (Houston) 11% 25% 64% Humana Health Plan of Houston (Houston) 6% 21% 73% Scott and White Health Plan (Central Texas) 9% 24% 67% United Healthcare of Texas, Inc. (Houston/San Antonio) 12% 25% 63% Office of Public Insurance Counsel 40 Comparing Texas HMOs 2014 Gulf Coast Texas

43 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Houston) Humana Health Plan of Houston (Houston) Scott and White Health Plan (Central Texas) United Healthcare of Texas, Inc. (Houston/San Antonio) 9% 24% 68% 12% 25% 63% 14% 31% 55% 8% 6% 2 8% 9% 22% 70% 28% 66% 26% 72% 16% 76% 23% 68% - Gulf Coast Texas Office of Public Insurance Counsel 41 Comparing Texas HMOs 2014 Gulf Coast Texas

44 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests or treatment they needed through their health plan. 13% 30% 56% Aetna Health, Inc. (Houston) 13% 28% 59% CIGNA HealthCare of Texas, Inc. (South Texas) 13% 32% 55% FIRSTCARE (Waco) 11% 35% 54% 14% 32% 54% HMO Blue Texas (Houston) 14% 36% 51% Humana Health Plan of Houston (Houston) 14% 33% 52% Scott and White Health Plan (Central Texas) 16% 29% 55% United Healthcare of Texas, Inc. (Houston/San Antonio) 14% 28% 58% Office of Public Insurance Counsel 42 Comparing Texas HMOs 2014 Gulf Coast Texas

45 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Houston) Humana Health Plan of Houston (Houston) Scott and White Health Plan (Central Texas) United Healthcare of Texas, Inc. (Houston/San Antonio) 16% 22% 62% 17% 22% 61% 14% 30% 56% 12% 27% 61% 20% 24% 56% 19% 23% 57% 16% 27% 57% 19% 24% 57% - Gulf Coast Texas Office of Public Insurance Counsel 43 Comparing Texas HMOs 2014 Gulf Coast Texas

46 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% Aetna Health, Inc. (Houston) 6% 18% 76% CIGNA HealthCare of Texas, Inc. (South Texas) 6% 16% 78% FIRSTCARE (Waco) 5 17% 78% 6% 20% 74% HMO Blue Texas (Houston) 9% 18% 73% Humana Health Plan of Houston (Houston) 6% 21% 73% Scott and White Health Plan (Central Texas) 4 20% 77% United Healthcare of Texas, Inc. (Houston/San Antonio) 10% 21% 69% Office of Public Insurance Counsel 44 Comparing Texas HMOs 2014 Gulf Coast Texas

47 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Houston) Humana Health Plan of Houston (Houston) Scott and White Health Plan (Central Texas) United Healthcare of Texas, Inc. (Houston/San Antonio) 12% 34% 10% 35% 12% 38% 13% 35% 21% 28% 10% 33% 23% 33% 19% 29% 54% 56% 50% 52% 51% 57% 45% 52% - Gulf Coast Texas Office of Public Insurance Counsel 45 Comparing Texas HMOs 2014 Gulf Coast Texas

48 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% Aetna Health, Inc. (Houston) 14% 19% 68% CIGNA HealthCare of Texas, Inc. (South Texas) 9% 21% 69% FIRSTCARE (Waco) 10% 23% 67% 16% 26% 59% HMO Blue Texas (Houston) 9% 26% 64% Humana Health Plan of Houston (Houston) 10% 26% 64% Scott and White Health Plan (Central Texas) 17% 18% 65% United Healthcare of Texas, Inc. (Houston/San Antonio) 19% 21% 60% Office of Public Insurance Counsel 46 Comparing Texas HMOs 2014 Gulf Coast Texas

49 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% Aetna Health, Inc. (Houston) CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Waco) HMO Blue Texas (Houston) Humana Health Plan of Houston (Houston) Scott and White Health Plan (Central Texas) United Healthcare of Texas, Inc. (Houston/San Antonio) 38% 32% 30% 38% 37% 25% 48% 30% 23% 34% 37% 29% 34% 26% 40% 50% 27% 22% 45% 31% 24% 42% 29% 29% - Gulf Coast Texas Office of Public Insurance Counsel 47 Comparing Texas HMOs 2014 Gulf Coast Texas

50 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reasons you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% Aetna Health, Inc. (Houston) 19% 11% 28% 42% CIGNA HealthCare of Texas, Inc. (South Texas) 19% 12% 26% 43% FIRSTCARE (Waco) 14% 11% 25% 50% 14% 9% 27% 51% HMO Blue Texas (Houston) 17% 11% 25% 47% Humana Health Plan of Houston (Houston) 23% 10% 26% 40% Scott and White Health Plan (Central Texas) 18% 10% 25% 47% United Healthcare of Texas, Inc. (Houston/San Antonio) 20% 9% 27% 45% Office of Public Insurance Counsel 48 Comparing Texas HMOs 2014 Gulf Coast Texas

51 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 49 Comparing Texas HMOs 2014 Gulf Coast Texas

52 Office of Public Insurance Counsel 50 Comparing Texas HMOs 2014 Gulf Coast Texas

53 for North Texas Plans The counties included in the North Texas area are: Collin Fannin Navarro Wise Cooke Grayson Palo Pinto Dallas Hood Parker Denton Hunt Rockwall Erath Johnson Somervell Ellis Kaufman Tarrant This section features survey results for plans that serve the North Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers greater access to data to compare HMOs. Office of Public Insurance Counsel 51 Comparing Texas HMOs 2014 North Texas

54 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% Aetna Health, Inc. (Dallas/Fort Worth) 17% 36% 47% FIRSTCARE (Waco) 26% 45% 29% HMO Blue Texas (Dallas/Fort Worth) 10% 33% 56% 12% 38% 50% Humana Health Plan of Texas (Austin) 17% 38% 45% Scott and White Health Plan (Central Texas) 23% 32% 44% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 29% 40% 31% Office of Public Insurance Counsel 52 Comparing Texas HMOs 2014 North Texas

55 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% Aetna Health, Inc. (Dallas/Fort Worth) 13% 32% 54% FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Scott and White Health Plan (Central Texas) United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 16% 38% 46% 9% 37% 55% 11% 32% 57% 11% 41% 49% 11% 34% 55% 11% 36% 53% - North Texas Office of Public Insurance Counsel 53 Comparing Texas HMOs 2014 North Texas

56 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% Aetna Health, Inc. (Dallas/Fort Worth) 6% 24% 70% FIRSTCARE (Waco) 7% 23% 70% HMO Blue Texas (Dallas/Fort Worth) 9% 28% 64% 10% 23% 67% Humana Health Plan of Texas (Austin) 9% 19% 72% Scott and White Health Plan (Central Texas) 9% 24% 67% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 10% 24% 67% Office of Public Insurance Counsel 54 Comparing Texas HMOs 2014 North Texas

57 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% Aetna Health, Inc. (Dallas/Fort Worth) 9% 24% 67% FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Scott and White Health Plan (Central Texas) United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% 31% 55% 8% 19% 8% 22% 6% 16% 8% 16% 13% 24% 73% 70% 79% 76% 63% - North Texas Office of Public Insurance Counsel 55 Comparing Texas HMOs 2014 North Texas

58 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests or treatment they needed through their health plan. 13% 30% 56% Aetna Health, Inc. (Dallas/Fort Worth) 11% 24% 65% FIRSTCARE (Waco) 11% 35% 54% HMO Blue Texas (Dallas/Fort Worth) 12% 31% 57% 14% 32% 54% Humana Health Plan of Texas (Austin) 8% 33% 59% Scott and White Health Plan (Central Texas) 16% 29% 55% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 16% 26% 58% Office of Public Insurance Counsel 56 Comparing Texas HMOs 2014 North Texas

59 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% Aetna Health, Inc. (Dallas/Fort Worth) 10% 25% 64% FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Scott and White Health Plan (Central Texas) United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% 30% 56% 13% 23% 64% 12% 27% 61% 16% 24% 59% 16% 27% 57% 18% 28% 53% - North Texas Office of Public Insurance Counsel 57 Comparing Texas HMOs 2014 North Texas

60 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% Aetna Health, Inc. (Dallas/Fort Worth) 4 22% 74% FIRSTCARE (Waco) 5 17% 78% HMO Blue Texas (Dallas/Fort Worth) 5 22% 73% 6% 20% 74% Humana Health Plan of Texas (Austin) 6% 18% 76% Scott and White Health Plan (Central Texas) 4 20% 77% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 5 15% 80% Office of Public Insurance Counsel 58 Comparing Texas HMOs 2014 North Texas

61 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% Aetna Health, Inc. (Dallas/Fort Worth) 14% 34% 52% FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Scott and White Health Plan (Central Texas) United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 12% 38% 50% 9% 34% 57% 13% 35% 52% 14% 33% 53% 23% 33% 45% 13% 37% 50% - North Texas Office of Public Insurance Counsel 59 Comparing Texas HMOs 2014 North Texas

62 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% Aetna Health, Inc. (Dallas/Fort Worth) 15% 31% 55% FIRSTCARE (Waco) 10% 23% 67% HMO Blue Texas (Dallas/Fort Worth) 12% 19% 68% 16% 26% 59% Humana Health Plan of Texas (Austin) 17% 21% 62% Scott and White Health Plan (Central Texas) 17% 18% 65% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 25% 28% 48% Office of Public Insurance Counsel 60 Comparing Texas HMOs 2014 North Texas

63 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% Aetna Health, Inc. (Dallas/Fort Worth) 36% 34% 30% FIRSTCARE (Waco) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Scott and White Health Plan (Central Texas) United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 48% 30% 23% 33% 21% 46% 34% 37% 29% 40% 29% 31% 45% 31% 24% 43% 29% 27% - North Texas Office of Public Insurance Counsel 61 Comparing Texas HMOs 2014 North Texas

64 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reasons you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% Aetna Health, Inc. (Dallas/Fort Worth) 19% 12% 26% 43% FIRSTCARE (Waco) 14% 11% 25% 50% HMO Blue Texas (Dallas/Fort Worth) 17% 12% 26% 46% 14% 9% 27% 51% Humana Health Plan of Texas (Austin) 18% 15% 19% 48% Scott and White Health Plan (Central Texas) 18% 10% 25% 47% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 15% 7% 30% 48% Office of Public Insurance Counsel 62 Comparing Texas HMOs 2014 North Texas

65 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 63 Comparing Texas HMOs 2014 North Texas

66 Office of Public Insurance Counsel 64 Comparing Texas HMOs 2014 North Texas

67 for Panhandle/Plains Texas Plans The counties included in the Panhandle/Plains Texas area are: Andrews Briscoe Cochran Crane Donley Hutchinson Montague Sterling Archer Brown Coke Crockett Eastland Irion Moore Stonewall Armstrong Callahan Coleman Crosby Ector Jack Motley Sutton Bailey Carson Collingsworth Dallam Fisher Jones Nolan Swisher Baylor Castro Comanche Dawson Floyd Kent Ochiltree Taylor Borden Childress Concho Deaf Smith Foard Kimble Oldham Terrell Clay Cottle Dickens Gaines King Parmer Terry Garza Knox Pecos Throckmorton Glasscock Lamb Potter Tom Green Gray Lipscomb Randall Upton Hale Loving Reagan Ward Hall Lubbock Reeves Wheeler Hansford Lynn Roberts Wichita Hardeman Martin Runnels Wilbarger Hartley Mason Schleicher Winkler Haskell McCulloch Scurry Yoakum Hemphill Menard Shackelford Young Hockley Midland Sherman Howard Mitchell Stephens This section features survey results for plans that serve the Panhandle/Plains Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers greater access to data to compare HMOs. Office of Public Insurance Counsl 65 Comparing Texas HMOs 2014 Panhandle/Plains

68 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% CIGNA HealthCare of Texas, Inc. (South Texas) 21% 35% 44% FIRSTCARE (Abilene) 20% 44% 36% FIRSTCARE (Amarillo) 19% 39% 42% FIRSTCARE (Lubbock) 24% 36% 40% HMO Blue Texas (Dallas/Fort Worth) 10% 33% 56% 12% 38% 50% Humana Health Plan of Texas (Austin) 17% 38% 45% Humana Health Plan of Texas (Houston) 22% 31% 47% Scott and White Health Plan (Central Texas) 23% 32% 44% Office of Public Insurance Counsel 66 Comparing Texas HMOs 2014 Panhandle/Plains

69 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Abilene) FIRSTCARE (Amarillo) FIRSTCARE (Lubbock) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Humana Health Plan of Texas (Houston) Scott and White Health Plan (Central Texas) 14% 32% 54% 12% 33% 56% 11% 39% 50% 15% 29% 56% 9% 37% 55% 11% 32% 57% 11% 41% 49% 14% 35% 52% 11% 34% 55% - Panhandle/Plains Texas Office of Public Insurance Counsel 67 Comparing Texas HMOs 2014 Panhandle/Plains

70 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% CIGNA HealthCare of Texas, Inc. (South Texas) 11% 22% 67% FIRSTCARE (Abilene) 8% 19% 74% FIRSTCARE (Amarillo) 6% 27% 67% FIRSTCARE (Lubbock) 5 21% 74% HMO Blue Texas (Dallas/Fort Worth) 9% 28% 64% 10% 23% 67% Humana Health Plan of Texas (Austin) 9% 19% 72% Humana Health Plan of Texas (Houston) 6% 21% 73% Scott and White Health Plan (Central Texas) 9% 24% 67% Office of Public Insurance Counsel 68 Comparing Texas HMOs 2014 Panhandle/Plains

71 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Abilene) FIRSTCARE (Amarillo) FIRSTCARE (Lubbock) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Humana Health Plan of Texas (Houston) Scott and White Health Plan (Central Texas) 12% 25% 63% 6% 19% 74% 8% 26% 66% 9% 27% 63% 8% 19% 73% 8% 22% 70% 6% 16% 79% 2 26% 72% 8% 16% 76% - Panhandle/Plains Texas Office of Public Insurance Counsel 69 Comparing Texas HMOs 2014 Panhandle/Plains

72 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests or treatment they needed through their health plan. 13% 30% 56% CIGNA HealthCare of Texas, Inc. (South Texas) 13% 32% 55% FIRSTCARE (Abilene) 12% 32% 56% FIRSTCARE (Amarillo) 13% 29% 58% FIRSTCARE (Lubbock) 11% 30% 59% HMO Blue Texas (Dallas/Fort Worth) 12% 31% 57% 14% 32% 54% Humana Health Plan of Texas (Austin) 8% 33% 59% Humana Health Plan of Texas (Houston) 14% 33% 52% Scott and White Health Plan (Central Texas) 16% 29% 55% Office of Public Insurance Counsel 70 Comparing Texas HMOs 2014 Panhandle/Plains

73 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Abilene) FIRSTCARE (Amarillo) FIRSTCARE (Lubbock) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Humana Health Plan of Texas (Houston) Scott and White Health Plan (Central Texas) 17% 22% 61% 13% 29% 58% 15% 24% 62% 12% 24% 64% 13% 23% 64% 12% 27% 61% 16% 24% 59% 19% 23% 57% 16% 27% 57% - Panhandle/Plains Texas Office of Public Insurance Counsel 71 Comparing Texas HMOs 2014 Panhandle/Plains

74 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% CIGNA HealthCare of Texas, Inc. (South Texas) 6% 16% 78% FIRSTCARE (Abilene) 4 17% 78% FIRSTCARE (Amarillo) 3 20% 77% FIRSTCARE (Lubbock) 5 19% 77% HMO Blue Texas (Dallas/Fort Worth) 5 22% 73% 6% 20% 74% Humana Health Plan of Texas (Austin) 6% 18% 76% Humana Health Plan of Texas (Houston) 6% 21% 73% Scott and White Health Plan (Central Texas) 4 20% 77% Office of Public Insurance Counsel 72 Comparing Texas HMOs 2014 Panhandle/Plains

75 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Abilene) FIRSTCARE (Amarillo) FIRSTCARE (Lubbock) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Humana Health Plan of Texas (Houston) Scott and White Health Plan (Central Texas) 10% 35% 56% 9% 36% 55% 10% 37% 54% 9% 36% 55% 9% 34% 57% 13% 35% 52% 14% 33% 53% 10% 33% 57% 23% 33% 45% - Panhandle/Plains Texas Office of Public Insurance Counsel 73 Comparing Texas HMOs 2014 Panhandle/Plains

76 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% CIGNA HealthCare of Texas, Inc. (South Texas) 9% 21% 69% FIRSTCARE (Abilene) 13% 29% 59% FIRSTCARE (Amarillo) 17% 25% 58% FIRSTCARE (Lubbock) 17% 24% 58% HMO Blue Texas (Dallas/Fort Worth) 12% 19% 68% 16% 26% 59% Humana Health Plan of Texas (Austin) 17% 21% 62% Humana Health Plan of Texas (Houston) 10% 26% 64% Scott and White Health Plan (Central Texas) 17% 18% 65% Office of Public Insurance Counsel 74 Comparing Texas HMOs 2014 Panhandle/Plains

77 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% CIGNA HealthCare of Texas, Inc. (South Texas) FIRSTCARE (Abilene) FIRSTCARE (Amarillo) FIRSTCARE (Lubbock) HMO Blue Texas (Dallas/Fort Worth) Humana Health Plan of Texas (Austin) Humana Health Plan of Texas (Houston) Scott and White Health Plan (Central Texas) 38% 37% 25% 45% 29% 26% 39% 37% 24% 52% 31% 17% 33% 21% 46% 34% 37% 29% 40% 29% 31% 50% 27% 22% 45% 31% 24% - Panhandle/Plains Texas Office of Public Insurance Counsel 75 Comparing Texas HMOs 2014 Panhandle/Plains

78 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reasons you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% CIGNA HealthCare of Texas, Inc. (South Texas) 19% 12% 26% 43% FIRSTCARE (Abilene) 15% 9% 25% 51% FIRSTCARE (Amarillo) 17% 11% 24% 49% FIRSTCARE (Lubbock) 21% 11% 22% 46% HMO Blue Texas (Dallas/Fort Worth) 17% 12% 26% 46% 14% 9% 27% 51% Humana Health Plan of Texas (Austin) 18% 15% 19% 48% Humana Health Plan of Texas (Houston) 23% 10% 26% 40% Scott and White Health Plan (Central Texas) 18% 10% 25% 47% Office of Public Insurance Counsel 76 Comparing Texas HMOs 2014 Panhandle/Plains

79 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 77 Comparing Texas HMOs 2014 Panhandle/Plains

80 Office of Public Insurance Counsel 78 Comparing Texas HMOs 2014 Panhandle/Plains

81 for South Texas Plans The counties included in the South Texas area are: Aransas Cameron Gillespie Jim Wells La Salle Real Webb Atascosa Comal Goliad Karnes Lavaca Refugio Willacy Bandera De Witt Gonzales Kendall Live Oak San Patricio Wilson Bee Dimmitt Guadalupe Kenedy Maverick Starr Zapata Bexar Duval Hidalgo Kerr McMullen Uvalde Zavala Brooks Edwards Jackson Kinney Medina Val Verde Calhoun Frio Jim Hogg Kleberg Nueces Victoria This section features survey results for plans that serve the South Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers greater access to data to compare HMOs. Office of Public Insurance Counsel 79 Comparing Texas HMOs 2014 South Texas

82 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% 34% 46% CIGNA HealthCare of Texas, Inc. (South Texas) 21% 35% 44% Community First Health Plans (San Antonio) 22% 38% 40% 12% 38% 50% Humana Health Plan of Texas (Corpus Christi) 21% 28% 51% Humana Health Plan of Texas (San Antonio) 18% 29% 53% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% 33% 49% Office of Public Insurance Counsel 80 Comparing Texas HMOs 2014 South Texas

83 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% Aetna Health, Inc. (San Antonio/Corpus Christi) CIGNA HealthCare of Texas, Inc. (South Texas) Community First Health Plans (San Antonio) Humana Health Plan of Texas (Corpus Christi) Humana Health Plan of Texas (San Antonio) United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 15% 37% 48% 14% 32% 54% 20% 38% 41% 11% 32% 57% 12% 36% 52% 12% 33% 55% 17% 28% 55% - South Texas Office of Public Insurance Counsel 81 Comparing Texas HMOs 2014 South Texas

84 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% Aetna Health, Inc. (San Antonio/Corpus Christi) 13% 24% 63% CIGNA HealthCare of Texas, Inc. (South Texas) 11% 22% 67% Community First Health Plans (San Antonio) 18% 27% 55% 10% 23% 67% Humana Health Plan of Texas (Corpus Christi) 10% 14% 76% Humana Health Plan of Texas (San Antonio) 8% 20% 72% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 12% 25% 63% Office of Public Insurance Counsel 82 Comparing Texas HMOs 2014 South Texas

85 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% Aetna Health, Inc. (San Antonio/Corpus Christi) CIGNA HealthCare of Texas, Inc. (South Texas) Community First Health Plans (San Antonio) Humana Health Plan of Texas (Corpus Christi) Humana Health Plan of Texas (San Antonio) United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 12% 25% 63% 12% 25% 63% 10% 20% 69% 8% 22% 70% 12% 10% 78% 11% 16% 73% 9% 23% 68% - South Texas Office of Public Insurance Counsel 83 Comparing Texas HMOs 2014 South Texas

86 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests or treatment they needed through their health plan. 13% 30% 56% Aetna Health, Inc. (San Antonio/Corpus Christi) 15% 30% 55% CIGNA HealthCare of Texas, Inc. (South Texas) 13% 32% 55% Community First Health Plans (San Antonio) 19% 31% 49% 14% 32% 54% Humana Health Plan of Texas (Corpus Christi) 13% 28% 59% Humana Health Plan of Texas (San Antonio) 18% 27% 55% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 14% 28% 58% Office of Public Insurance Counsel 84 Comparing Texas HMOs 2014 South Texas

87 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed, when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% Aetna Health, Inc. (San Antonio/Corpus Christi) CIGNA HealthCare of Texas, Inc. (South Texas) Community First Health Plans (San Antonio) Humana Health Plan of Texas (Corpus Christi) Humana Health Plan of Texas (San Antonio) United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 15% 28% 57% 17% 22% 61% 27% 25% 49% 12% 27% 61% 17% 26% 58% 23% 27% 50% 19% 24% 57% - South Texas Office of Public Insurance Counsel 85 Comparing Texas HMOs 2014 South Texas

88 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% Aetna Health, Inc. (San Antonio/Corpus Christi) 8% 25% 68% CIGNA HealthCare of Texas, Inc. (South Texas) 6% 16% 78% Community First Health Plans (San Antonio) 11% 22% 67% 6% 20% 74% Humana Health Plan of Texas (Corpus Christi) 7% 15% 79% Humana Health Plan of Texas (San Antonio) 6% 18% 76% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 10% 21% 69% Office of Public Insurance Counsel 86 Comparing Texas HMOs 2014 South Texas

89 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% Aetna Health, Inc. (San Antonio/Corpus Christi) CIGNA HealthCare of Texas, Inc. (South Texas) Community First Health Plans (San Antonio) Humana Health Plan of Texas (Corpus Christi) Humana Health Plan of Texas (San Antonio) United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 7% 10% 15% 13% 10% 10% 19% 26% 35% 29% 35% 33% 29% 29% 68% 56% 55% 52% 58% 61% 52% - South Texas Office of Public Insurance Counsel 87 Comparing Texas HMOs 2014 South Texas

90 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% Aetna Health, Inc. (San Antonio/Corpus Christi) 10% 27% 63% CIGNA HealthCare of Texas, Inc. (South Texas) 9% 21% 69% Community First Health Plans (San Antonio) 12% 25% 63% 16% 26% 59% Humana Health Plan of Texas (Corpus Christi) 20% 22% 58% Humana Health Plan of Texas (San Antonio) 17% 19% 65% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% 21% 60% Office of Public Insurance Counsel 88 Comparing Texas HMOs 2014 South Texas

91 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% Aetna Health, Inc. (San Antonio/Corpus Christi) CIGNA HealthCare of Texas, Inc. (South Texas) Community First Health Plans (San Antonio) Humana Health Plan of Texas (Corpus Christi) Humana Health Plan of Texas (San Antonio) United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 40% 29% 31% 38% 37% 25% 38% 29% 33% 34% 37% 29% 39% 32% 29% 38% 31% 31% 42% 29% 29% - South Texas Office of Public Insurance Counsel 89 Comparing Texas HMOs 2014 South Texas

92 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reason you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% Aetna Health, Inc. (San Antonio/Corpus Christi) 16% 13% 24% 47% CIGNA HealthCare of Texas, Inc. (South Texas) 19% 12% 26% 43% Community First Health Plans (San Antonio) 21% 8% 25% 46% 14% 9% 27% 51% Humana Health Plan of Texas (Corpus Christi) 16% 11% 25% 48% Humana Health Plan of Texas (San Antonio) 15% 11% 25% 49% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 20% 9% 27% 45% Office of Public Insurance Counsel 90 Comparing Texas HMOs 2014 South Texas

93 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 91 Comparing Texas HMOs 2014 South Texas

94 Office of Public Insurance Counsel 92 Comparing Texas HMOs 2014 South Texas

95 for West Texas Plans The counties included in the West Texas area are: Brewster Culberson El Paso Hudspeth Jeff Davis Presidio This section features survey results for plans that serve the West Texas area. It includes HMOs with a service area that extends into at least one county in the region. The city/area shown after the name indicates the primary area of service. Contact plans directly for details on specific service areas. An HMO may be exempt from participation in the survey due to low enrollment or limited participation in the Texas commercial HMO market during NCQA requires 100 responses to report survey results. OPIC has opted to report data based on 30 or more responses to provide consumers greater access to data to compare HMOs. Office of Public Insurance Counsel 93 Comparing Texas HMOs 2014 West Texas

96 How people rated their health plan Percentage who rated their plan 6 or lower Percentage who rated their plan 7 or 8 Percentage who rated their plan 9 or 10 The bar graphs show answers to a survey question that asked people to rate their health plan on a scale from: 0 = worst health plan possible to 10 = best health plan possible 20% 36% 44% FIRSTCARE (Lubbock) 24% 36% 40% 12% 38% 50% Humana Health Plan of Texas (Austin) 17% 38% 45% Office of Public Insurance Counsel 94 Comparing Texas HMOs 2014 West Texas

97 How people rated their healthcare Percentage who rated their care 6 or lower Percentage who rated their care 7 or 8 Percentage who rated their care 9 or 10 The bar graphs show answers to a survey question that asked people to rate their healthcare on a scale from: 0 = worst healthcare possible to 10 = best healthcare possible 13% 35% 52% FIRSTCARE (Lubbock) Humana Health Plan of Texas (Austin) 15% 29% 56% 11% 32% 57% 11% 41% 49% - West Texas Office of Public Insurance Counsel 95 Comparing Texas HMOs 2014 West Texas

98 How people rated their personal doctor Percentage who rated their personal doctor 6 or lower Percentage who rated their personal doctor 7 or 8 Percentage who rated their personal doctor 9 or 10 The bar graphs show answers to a survey question that asked people to rate their personal doctor on a scale from: 0 = worst personal doctor possible to 10 = best personal doctor possible 9% 23% 68% FIRSTCARE (Lubbock) 5 21% 74% 10% 23% 67% Humana Health Plan of Texas (Austin) 9% 19% 72% Office of Public Insurance Counsel 96 Comparing Texas HMOs 2014 West Texas

99 How people rated their specialist Percentage who rated their specialist 6 or lower Percentage who rated their specialist 7 or 8 Percentage who rated their specialist 9 or 10 The bar graphs show answers to a survey question that asked people to rate their specialist on a scale from: 0 = worst specialist possible to 10 = best specialist possible 9% 23% 69% FIRSTCARE (Lubbock) Humana Health Plan of Texas (Austin) 9% 27% 63% 8% 22% 70% 6% 16% 79% - West Texas Office of Public Insurance Counsel 97 Comparing Texas HMOs 2014 West Texas

100 Getting needed care sometimes or never received care that was needed usually received care that was needed always received care that was needed The bar graphs show answers to survey questions that asked people how often it was easy for them to: Get appointments with specialists. Get care, tests or treatment they needed through their health plan. 13% 30% 56% FIRSTCARE (Lubbock) 11% 30% 59% 14% 32% 54% Humana Health Plan of Texas (Austin) 8% 33% 59% Office of Public Insurance Counsel 98 Comparing Texas HMOs 2014 West Texas

101 Getting care quickly sometimes or never got care quickly usually got care quickly always got care quickly The bar graphs show answers to survey questions that asked people how often they: Got care as soon as they thought they needed, when they needed care right away. Got an appointment as soon as they thought they needed when they did not need care right away. 16% 25% 58% FIRSTCARE (Lubbock) Humana Health Plan of Texas (Austin) 12% 24% 64% 12% 27% 61% 16% 24% 59% - West Texas Office of Public Insurance Counsel 99 Comparing Texas HMOs 2014 West Texas

102 How well doctors communicate Percentage who said their doctors sometimes or never communicated well Percentage who said their doctors usually communicated well Percentage who said their doctors always communicated well The bar graphs show answers to survey questions that asked people how often their personal doctor: Explained things in a way that was easy for them to understand. Listened carefully to them. Showed respect for what they had to say. Spent enough time with them. 6% 19% 75% FIRSTCARE (Lubbock) 5 19% 77% 6% 20% 74% Humana Health Plan of Texas (Austin) 6% 18% 76% Office of Public Insurance Counsel 100 Comparing Texas HMOs 2014 West Texas

103 Handling of claims quickly and correctly Percentage who said their plan sometimes or never handled claims quickly and correctly Percentage who said their plan Usually handled claims quickly and correctly Percentage who said their plan Always handled claims quickly and correctly The bar graphs show answers to survey questions that asked people how often their health plan: Handled claims quickly. Handled claims correctly. 12% 33% 55% FIRSTCARE (Lubbock) Humana Health Plan of Texas (Austin) 9% 36% 55% 13% 35% 52% 14% 33% 53% - West Texas Office of Public Insurance Counsel 101 Comparing Texas HMOs 2014 West Texas

104 Health plan customer service Percentage who said customer service was sometimes or never efficient and helpful Percentage who said customer service was usually efficient and helpful Percentage who said customer service was always efficient and helpful The bar graphs show answers to survey questions that asked people how often: They got the information or help they needed from their health plan s customer service. Their health plan s customer service staff treated them with courtesy and respect. 14% 24% 62% FIRSTCARE (Lubbock) 17% 24% 58% 16% 26% 59% Humana Health Plan of Texas (Austin) 17% 21% 62% Office of Public Insurance Counsel 102 Comparing Texas HMOs 2014 West Texas

105 Plan information on costs sometimes or never were able to find out cost info Usually were able to find out cost info Always were able to find out cost info The bar graphs show answers to survey questions that asked people how often they were able to find out from their plan: How much would have to be paid for a healthcare service or equipment. How much would have to be paid for specific prescription medicines. 40% 31% 29% FIRSTCARE (Lubbock) Humana Health Plan of Texas (Austin) 52% 31% 17% 34% 37% 29% 40% 29% 31% - West Texas Office of Public Insurance Counsel 103 Comparing Texas HMOs 2014 West Texas

106 Shared Decision Making Percentage who said there was Not at all or No shared decision making Percentage who said there was A little shared decision making Percentage who said there was Some shared decision making Percentage who said there was A lot or Yes shared decision making The bar graphs show answers to survey questions that asked how much when starting or stopping a medicine: A doctor or other health provider talk about the reasons you might want to take a medicine? A doctor or other health provider talk about the reasons you might not want to take a medicine? Whether a doctor or other health provider ask you what you thought was best for you? (Yes or No) 17% 11% 25% 47% FIRSTCARE (Lubbock) 21% 11% 22% 46% 14% 9% 27% 51% Humana Health Plan of Texas (Austin) 18% 15% 19% 48% Office of Public Insurance Counsel 104 Comparing Texas HMOs 2014 West Texas

107 Response rate for all plans in the survey Response rate = (completed surveys / [total sample ineligible]) State Average = 25% Aetna Health, Inc. (Austin) 19% Aetna Health, Inc. (Dallas/Fort Worth) 21% Aetna Health, Inc. (Houston) 22% Aetna Health, Inc. (San Antonio/Corpus Christi) 20% CIGNA HealthCare of Texas, Inc. (South Texas) 19% Community First Health Plans (San Antonio) 28% FIRSTCARE (Abilene) 32% FIRSTCARE (Amarillo) 40% FIRSTCARE (Lubbock) 30% FIRSTCARE (Waco) 31% HMO Blue Texas (Dallas/Fort Worth) 22% 26% HMO Blue Texas (Houston) 19% Humana Health Plan of Texas (Austin) 23% Humana Health Plan of Texas (Corpus Christi) 24% Humana Health Plan of Texas (Houston) 25% Humana Health Plan of Texas (San Antonio) 27% Scott and White Health Plan (Central Texas) 36% United Healthcare Benefits of Texas, Inc. (Austin/Dallas) 14% United Healthcare Benefits of Texas, Inc. (Houston/San Antonio) 19% Office of Public Insurance Counsel 105 Comparing Texas HMOs 2014 West Texas

108 Office of Public Insurance Counsel 106 Comparing Texas HMOs 2014 West Texas

109 Section 3: Complaints Against HMOs and Appeals Office of Public Insurance Counsel 107 Comparing Texas HMOs 2014

110 HMO Complaint Data The Texas Department of Insurance (TDI) handles complaints against HMOs regarding the quality and availability of medical care as well as an HMO s administrative procedures (claims, billing, enrollment, appeals, etc.). A high frequency of justified complaints against an HMO can indicate high consumer or provider dissatisfaction with the company. This section reports data as maintained by TDI. The years measured run July 1 to June 30. In 2012, TDI changed the complaint data it publishes to only include complaints TDI deems justified. In the past, other types of complaints were included in the reported data. TDI defines a complaint as justified if there is an apparent violation of a policy provision, contract provision, rule, or statute, or there is a valid concern that a prudent layperson would regard as a practice or service that is below customary business or medical practice. OPIC does not (1) audit or independently verify the validity of complaints, (2) TDI s determination of justified complaints, or (3) the enrollment data reported in this section. For more information on TDI s complaint process, contact the Consumer Help Line at (800) or visit You may direct complaints against healthcare providers to the appropriate licensing agency. Common Reasons for Complaint Reason for Complaint Delays in Claims Handling Denial of Claim Provider or consumer complaint regarding the timeliness of claims handling Provider or consumer complaint related to denial of coverage for healthcare service 12.9% 18.6% 8.3% 16.3% 13.3% 11.6% 24.3% 28.1% 29.8% 22.3% Unsatisfactory Settlement Offer Provider complaint regarding HMO compensation for services 6.7% 21.4% 44.3% 27.0% 38.3% Access to Care Balance Billing Timely Filing Deficiency Recoupment of Claims Payment Consumer complaint that HMO denied reimbursement for necessary care Consumer complaint that provider billed in excess of HMO contracted rate Dispute between an HMO and a provider regarding the timely filing of a claim Provider complaint regarding overpayment dispute resolution 6.7% 0.7% 0.0% 2.4% 0.3% 0.5% - 2.1% 1.6% 0.9% 0.3% 2.9% 0.0% 0.0% 0.0% - 4.3% 2.1% 3.6% 4.3% Source: Texas Department of Insurance July 1, 2009 June 30, 2014 Office of Public Insurance Counsel 108 Comparing Texas HMOs 2014

111 Most Common Reasons for Complaint Percent of Total Complaints 40% 35% 30% 25% 20% 15% 10% 22.3% Denial of of Claim 29.8% 28.1% 24.3% Reporting Year 11.6% Percent of Total Complaints 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 38.3% Unsatisfactory Settlement Offer 27.0% 44.3% 21.4% Reporting Year 6.7% Percent of Total Complaints 25% 20% 15% 10% 5% 13.3% Delays in Claims Handling 16.3% 8.3% 18.6% 12.9% Reporting Year Office of Public Insurance Counsel 109 Comparing Texas HMOs 2014

112 Complaint Trends: Basic Service HMOs The chart below illustrates the rate of justified complaints (number of justified complaints per 10,000 enrollees) for all basic service HMOs. While the rate of justified complaints filed by providers has decreased steadily since 2010, the justified complaint rate for consumers/ patients increased in This is attributed to a significant increase in complaints from January 1, 2014 to June 30, The increase in complaints includes many administrative complaints such as delays in furnishing information to consumers, failure to properly disclose provider networks, failure to properly inform consumers of prescription drug coverage/copays/ limits, and improperly expecting additional payment. This results in an overall increase in the rate of justified complaints (consumers/patients and providers combined) in Complaint Frequency: Reporting Years Basic Service HMOs 2.5 Complaints Per 10,000 Enrollees 2.0 Number of Complaints Patient Provider Total Complaints Filed Reporting Year Source: Texas Department of Insurance July 1, 2009 June 30, 2014 Office of Public Insurance Counsel 110 Comparing Texas HMOs 2014

113 Complaint Trends: Basic Service HMOs with Commercial Enrollment Over 1,000 The chart below reports complaint data for basic service HMOs with commercial enrollment over 1,000. The chart provides justified complaint data for the 2014 reporting year. Complaint Data: 2014 Reporting Year Basic Service HMOs with Commercial Enrollment over 1,000 HMO Commercial Enrollment March 2014 Consumer Complaints Healthcare Provider Complaints Consumer and Provider Complaints (Combined) Consumer Complaints Per 10,000 Enrollment Healthcare Provider Complaints Per 10,000 Enrollment Consumer and Provider Complaints (Combined) Per 10,000 Enrollment Aetna Health, Inc. 57, CIGNA HealthCare of Texas, Inc. 14, FIRSTCARE 42, HMO Blue Texas 132, Humana Health Plan of Texas, Inc. 253, Scott and White Health Plan 86, United HealthCare Benefits of Texas, Inc. 2, TOTAL/AVERAGE BASIC SERVICE 589, Average complaint ratios are calculated excluding the high and low value in each column. Source: Texas Department of Insurance July 1, 2013 June 30, 2014 Source Data: Texas Department of Insurance (TDI) Internet Complaints Information Systems (ICIS) complaint data was downloaded from the TDI s website for use in this report. Complaints were counted as follows: (a) Subject of Complaint = Home Maintenance Organization, (b) Line of Coverage = Accident & Health and using a combination of unique complaint ID, reason for complaint and correspondent. The chart excludes additional records with the same ID and reason for complaint as those already counted. Office of Public Insurance Counsel 111 Comparing Texas HMOs 2014

114 Denials, Appeals, and Independent Review Organizations Your HMO will review your coverage for a treatment, service, or prescription either before or after your claim is filed. If your health plan refuses to pay for medically necessary services, treatments, or medications, you have the right to appeal the decision through the HMO s internal appeals process. Contact your HMO or your employer for details on the appeals process. If you have exhausted your internal appeal rights, you may have the right to have the decision reviewed by an independent review organization (IRO). Your health plan must provide an independent review form if it denies payment based on a decision that the treatment is unnecessary, inappropriate, experimental, or investigational. Your health plan must pay for the review and must comply with the IRO s decision. The IRO must issue a decision within twenty days for non-emergency treatment and within five days for emergency treatment. The law does not require an HMO to provide an IRO for services it does not cover. It also does not require certain types of plans Medicare, Medicaid, and ERISA plans, for example to participate in the IRO process. For more information on IROs, contact TDI s Health and Workers Compensation Network Certification and Quality Assurance Office at IRO Appeals HMO Cases Cases Decided in Favor of the HMO Cases Decided in Favor of the Patient / Enrollee Cases Decided Partially in Favor of Both Aetna Health, Inc CIGNA HealthCare of Texas, Inc Community First Health Plans, Inc FIRSTCARE HMO Blue Texas Humana Health Plan of Texas, Inc Scott and White Health Plan TOTAL Source: Texas Department of Insurance IRO Database July 1, 2013 June 30, 2014 Office of Public Insurance Counsel 112 Comparing Texas HMOs 2014

115 Section 4: Additional Information Office of Public Insurance Counsel 113 Comparing Texas HMOs 2014

116 Who performed the survey? About the Survey Independent survey vendors certified by the National Committee for Quality Assurance (NCQA) performed the CAHPS 5.0H survey. NCQA is a not-for-profit organization committed to assessing, reporting on, and improving the quality of healthcare. State law requires Texas HMOs to submit consumer satisfaction data to the Department of State Health Services. Who was surveyed? The CAHPS 5.0H survey was sent to approximately 24,600 adult plan members across the state of Texas. Overall, 5,694 enrollees responded: 3,727 completed the survey by mail, 1,845 by phone, and 122 online. Only members who were enrolled continuously in an HMO from January 1, 2013 to December 31, 2013 were eligible to complete the survey. Members surveyed answered only questions pertaining to healthcare services they received during the survey period. Each survey result section contains the consumer response rate by plan. How was the survey performed? The survey vendors administered the survey primarily by mail with a telephone follow-up of those who did not respond to the mailed questionnaire. The survey was voluntary and confidential. The survey asked HMO members questions about their experiences with their health plans and medical care such as: Were your claims handled quickly and correctly? Were you able to get the care you needed? Could you get appointments quickly? Could you get the information you needed from your health plan? Office of Public Insurance Counsel 114 Comparing Texas HMOs 2014

117 HMO Market Share Data This table reports HMO enrollment and market share information for the first quarter of The data on the left side of the chart indicate total enrollment for basic service HMOs. The data on the right side provide enrollment information for basic service HMOs with commercial enrollment. HMO Total Ending Enrollment Total Market Share Commercial Ending Enrollment Commercial Market Share AdvantageOptimum 369, % % Aetna Health Inc. 144, % 57, % Cigna Healthcare of Texas, Inc. 14, % 14, % Community First Health Plans, Inc. 117, % 5, % Community Health Choice, Inc. 234, % % Health Care Service Corp. (HMO Blue Tex- 153, % 132, % Humana Health Plan of Texas, Inc. 328, % 253, % Molina Healthcare of Texas, Inc. 193, % % Scott & White Health Plan 146, % 86, % Sendero Health Plans, Inc. 12, % 1, % SHA, L.L.C. (FIRSTCARE) 137, % 42, % Superior Healthplan, Inc. 382, % % UnitedHealthcare Benefits of Texas, Inc. 187, % 2, % Unitedhealthcare of Texas, Inc % % UTMB Health Plans, Inc % % Valley Baptist Insurance Co. 9, % 7, % All other HMOs (including Medicare & Medi- 1,941, % 0 0.0% TOTAL BASIC SERVICE 4,371, % 606, % Source: Texas Department of Insurance HMO Financial Report First Quarter 2014 Office of Public Insurance Counsel 115 Comparing Texas HMOs 2014

118 HMO Financial Information The financial condition of a health plan can impact its ability to timely pay claims and, in extreme cases, may affect quality of care. OPIC encourages consumers to review all available information about an HMO s financial strength before contracting with the HMO. For financial strength ratings of Texas health plans, you may contact the following organizations: A.M. Best Company (908) Fitch Ratings, Ltd. (212) Moody's Investors Service (212) Standard and Poor s (212) Financial Services TheStreet.com Ratings, Inc. (800) You can obtain additional information by calling the Texas Department of Insurance customer service line at TDI also makes financial information available online via its Check Companies link at Plans Available Through the Federal Marketplace As of the date of publication, the following companies are selling HMO or Point of Service plans through the federal marketplace: Aetna Health, Inc. Ambetter (Superior Healthplan, Inc.) Blue Cross and Blue Shield of Texas Community First Health Plans, Inc. Community Health Choice Firstcare Health Plan Humana Health Plan of Texas, Inc. IdealCare (Sendero Health Plans, Inc.) Molina Marketplace (Molina Healthcare of Texas, Inc.) Scott and White Health Plan Please note that not all companies may sell plans in your area. You may purchase a plan through the federal marketplace at or by calling (TTY ). Office of Public Insurance Counsel 116 Comparing Texas HMOs 2014

119 Additional Sources of Information STATE RESOURCES Office of Public Insurance Counsel (OPIC) William P. Hobby State Office Building 333 Guadalupe, Suite Austin, Texas (877) OPIC is an independent state agency representing the interests of insurance consumers in Texas as a class on matters involving rates, rules, and policy forms affecting personal lines of insurance such as auto, homeowners, title, and credit insurance, and in rulemaking for life, accident, and health insurance. Texas Department of Insurance (TDI) P.O. Box Austin, Texas (800) TDI regulates HMOs in the state, including complaints, appeals, quality of care and financial stability. TDI has information about HMOs and health insurance in general, both in printed form and on the website. CHIP & Children s Medicaid P.O. Box Midland, Texas (877) The Texas Health and Human Services Commission offers two health insurance programs for children: Children s Health Insurance Program (CHIP) and Children s Medicaid. Applications, eligibility information and other related information can be obtained in printed form and from the website. Texas Health and Human Services Commission (HHSC) 4900 N. Lamar Blvd. Austin, Texas (800) or HHSC has oversight responsibilities for designated HHSC agencies, and administers certain health and human services programs including the Texas Medicaid Program and CHIP. Texas Health and Human Services Commission Office of the Ombudsman P. O. Box Austin, Texas (877) The Office of the Ombudsman assists consumers when the agency s normal complaint process cannot, or does not, satisfactorily resolve the individual s concerns. The Ombudsman supports inquiries and complaints about programs and services related to HHSC, Department of Aging and Disability Services (DADS), Department of Assistive and Rehabilitative Services (DARS), Department of Family and Protective Services (DFPS), and Department of State Health Services (DSHS). Texas Health and Human Services Commission Medicaid Managed Care Helpline (MMCH) P. O. Box Austin, Texas (866) MMCH assists Medicaid clients who are experiencing barriers to health and long term care services through their Texas Medicaid managed care programs: STAR, STAR+PLUS, or PCCM. Office of Public Insurance Counsel 117 Comparing Texas HMOs 2014

120 Texas Department of Aging and Disability Services (DADS) P.O. Box Austin, Texas (800) DADS coordinates a system of services and support for individuals over the age of 60 and individuals with disabilities. Employees Retirement System of Texas (ERS) P.O. Box Austin, Texas (877) (512) (Austin) ERS administers health, retirement, and other benefits for state agency and higher education employees whose employers participate in the Texas Uniform Group Insurance Program. Teacher Retirement System of Texas (TRS) 1000 Red River Street Austin, Texas (800) (512) (Austin) Texas Health Care Information Collection (THCIC) Department of State Health Services (DSHS) Center for Health Statistics, Mail Code 1898 P.O. Box Austin, Texas (512) THCIC collects data from hospitals and HMOs about quality of care and makes the information available to the public. Health Information, Counseling and Advocacy Program (HICAP) (800) HICAP is a partnership of the Texas Department of Insurance, Texas Legal Services Center, the Texas Department of Aging and Disabilities, and the Texas Area Agencies on Aging. The program provides information on health insurance and public benefits to individuals age 65 and older and individuals with disabilities. TRS administers health insurance and provides retirement and related benefits for active and retired employees of public schools, colleges, and universities supported by the state. TRS is the state's largest public retirement system. Office of Public Insurance Counsel 118 Comparing Texas HMOs 2014

121 FEDERAL RESOURCES Centers for Medicare and Medicaid Services (CMS) Region VI 1301 Young Street, Suite 714 Dallas, Texas (214) CMS oversees Medicare, Medicaid, the Children s Insurance Program (CHIP), HIPPA, and the Clinical Laboratory Improvement Amendments Program. United States Department of Labor Employee Benefits Security Administration (EBSA) (Dallas Regional Office) 525 South Griffin Street, Room 900 Dallas, Texas (972) United States Office of Personnel Management Federal Employees Health Benefit Program San Antonio Service Center 8610 Broadway, Room 305 San Antonio, Texas (210) The Office of Personnel Management publishes the Federal Employees Health Benefits Program Handbook, an annual guide on health benefit plans for federal civilian employees. The handbook compares and rates HMOs, fee-for-service and managed care health plans available to federal workers. Healthcare.gov Healthcare.gov is the health insurance marketplace portal for Texas. The site allows consumers to compare and purchase health coverage. Consumers can also find information on their rights. EBSA administers and enforces provisions of Title I of the Employee Retirement Income Security Act of 1974 (ERISA). EBSA publishes numerous documents and guides to provide workers with information regarding their benefit rights. NON-PROFIT RESOURCE Kaiser Family Foundation 2400 Sand Hill Road Menlo Park, California (650) The Kaiser Family Foundation is a non-profit, private foundation focusing on major health issues in the United States. It provides information and analysis for the public. Office of Public Insurance Counsel 119 Comparing Texas HMOs 2014

122 HMO Customer Service Contact Information Aetna Health, Inc. (800) CIGNA Healthcare of Texas, Inc. (800) Community First Health Plans, Inc. (800) Health Care Service Corp. (877) (HMO Blue Texas) Humana Health Plan of Texas, Inc. (800) Scott and White Health Plan (800) SHA, L.L.C. (FIRST CARE) (800) United HealthCare Benefits (800) (formerly PacifiCare of Texas) UTMB Health Plans, Inc. (866) Valley Baptist Insurance Co. (877) Office of Public Insurance Counsel 120 Comparing Texas HMOs 2014

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124 Please send questions or comments to: Office of Public Insurance Counsel Deeia Beck, Public Counsel William P. Hobby State Office Building 333 Guadalupe, Suite Austin, Texas fax TTY Users Call RELAY TX or OPIC RECYCLES