NC Consumer’s Guide to Health Plan Selection

Health care in North Carolina–as in the rest of the nation–is in a period of transition. Enrollment in managed care has grown steadily in the past decade: by the end of 1998, more than 1.2 million people were enrolled in health maintenance organizations (HMOs) or point-of-service plans (POS). While the exact number of people enrolled in preferred provider organizations (PPO) is not known, some experts estimate that more than one million North Carolinians are enrolled in PPOs. Many public and private employers now offer a managed care option to employees. The state of North Carolina offers a variety of managed care options to state employees and their dependents, and the state also has a portion of the Medicaid population enrolled in managed care plans.

In the past, employers generally chose one health insurance plan for their employees. Recently, however, more employers are offering workers a choice from among two or more health plans in a variety of formats. To help families, people with disabilities, other consumers, and employers choose the health plan that best meets their needs, the North Carolina Institute of Medicine (NC•IOM) developed this North Carolina Consumer’s Guide to Health Plan Selection, with the generous support of a grant from the North Carolina Council on Developmental Disabilities and the North Carolina Office of Research, Demonstrations and Rural Health Development.

This guide focuses on HMOs because they are the most different from traditional insurance plans of the past. HMOs are more likely to emphasize preventive services than are traditional insurance plans. However, unlike traditional insurance coverage, HMO members must obtain care from health care providers who are in the HMO’s network. Typically, HMO members also are required to obtain approval from their primary care provider before receiving care from a specialist. In addition, HMOs may shift part of the financial "risk" of caring for patients to the doctor through special payment mechanisms. While these payment mechanisms provide an incentive for providers to be efficient managers of care, some people worry that these payment mechanisms also may provide incentives to withhold necessary care. Finally, because states typically collect more information about HMOs than about traditional insurance companies or PPOs, more information was available on HMOs to include in this guide.

The Guide summarizes information on 13 HMOs that are currently operating in North Carolina: Aetna/US Healthcare, Blue Cross Blue Shield, Cigna/Healthsource, Doctors Health Plan, Generations, Optimum Choice, Partners National Health Plan, Principal Health Care of the Carolinas (now Coventry), Prudential Health Care Plan (now Aetna/US Healthcare), QualChoice, The Wellness Plan, United HealthCare, and WellPath Select. Principal Health Care of the Carolinas and Prudential Health Care Plan have been purchased by other HMOs (Coventry and Aetna respectively); therefore, we have renamed them whenever they are mentioned in the Guide. In addition, at the time of this publication, Generations was in the process of being sold to Partners and Wellpath was in the process of being sold to Coventry. Generations and Wellpath are still included as separate health plans because the sale had not been finalized at the time of publication, and these plans are still being marketed to the public. In addition, there are two other HMOs licensed in North Carolina that have some members: Open Health Plan and FirstCarolinaCare, Inc. We did not include them in this year's analysis, as they are relatively new, and have very limited membership.

The Guide includes basic information about how managed care works (Frequently Asked Questions), your rights if you are enrolled in a managed care organization (Consumer Protections), and your responsibilities as a managed care member (Member Responsibilities). The Guide also includes a section on questions that people should ask their managed care plans (Questions You Should Ask Your Managed Care Plans) and similar materials tailored to individuals with disabilities or other special health care needs (People with Disabilities & Managed Care: Questions You Should Ask Your Managed Care Plan). The Guide also includes basic information about the HMOs (Background Information about NC HMOs), and a comparison of the benefits covered or excluded under the HMO’s most commonly purchased health plans. Note that many plans can be customized–that is, services covered by an HMO may differ for employees of Company A than for those of Company B. Also, services covered by health plans can change regularly. Therefore, to obtain the most accurate information, review your own Evidence of Coverage. If you are in the process of choosing an HMO, ask your employer or call the HMO’s customer service number to obtain a copy of the appropriate Evidence of Coverage.

Information is provided about each HMO (HMO-Specific Information), including background information about the HMOs, product offerings, covered and excluded services, primary care provider and referral information, enrollment data, utilization review and financial data. In addition, side-by-side comparisons of the HMOs are provided for specific information: covered services (HMO Coverage of Specific Services), commonly-excluded benefits (Common Exclusions), enrollment trends (Enrollment Trends), financial data (Financial Data), and utilization reviews (utilization review). Because managed care terminology is often confusing, a glossary is also included along with a list of common acronyms or abbreviations (Glossary), as well as internet links to other managed care resources (Managed Care: Internet Resources for the General Population and Managed Care: Internet Resources for Individuals with Disabilities). We have also provided you with internet access to other NC health care resources, including: information about other publicly funded health care programs available to serve young children and their families (http://www.nciom.org/book), the NC Department of Insurance (http://www.ncdoi.com/ncdoi/Consumer/), the State Employees Health Plan (http://statehealthplan.state.nc.us/), the NC Department of Medical Assistance (Medicaid)(http://www.dhhs.state.nc.us/dma), NC HealthChoice (http://www.dhhs.state.nc.us/dma/cpcont.htm) and Medicare (http://www.medicare.gov).

Our hope is that this information will help you choose a health plan that can best meet your–and your family’s–health care needs. We hope to provide updated information in future editions and welcome your thoughts and comments on how the Guide might be improved.