AETNA/US HEALTHCARE OF THE CAROLINAS
Updated 9/2000

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000.

HMO General Information
Background information		Aetna/US Healthcare received its HMO license from the NC Department of Insurance on September 20, 1995, and commenced business that same day. Aetna/US Healthcare is a for-profit corporation. It is owned by Aetna, Inc., a Connecticut corporation.
Type of HMO		Aetna/US Healthcare operates an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Types of Products		Aetna/US Healthcare’s most commonly purchased HMO plan is a "gatekeeper" product. In a gatekeeper system, you must choose a primary care provider who is responsible for managing all your care. For example, your primary care provider would be required to refer you to a specialist, or authorize a non-emergency admission to the hospital. Aetna/US Healthcare also offers a point-of-service option called "Quality Point of Service."
Accreditation		Aetna/US Healthcare has not been accredited by an external accreditation organization. Not all health plans seek accreditation. The accreditation process is very expensive and some plans choose not to participate. This does not necessarily mean that Aetna/US Healthcare is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees		Aetna/US Healthcare offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group"), Medicare, or Medicaid recipients, although some Medicare beneficiaries may have supplemental HMO coverage through their employer.
Counties in which HMO has an Active Presence		Aetna/US Healthcare had at least 25 HMO commercial (group) members at the end of 1999 in the following North Carolina counties: Cabarrus, Catawba, Gaston, Hyde, Lincoln, Mecklenburg, Stanly, and Union.
Customer Service Number		1-800-323-9930
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: Semi-private medical room and board. Private room covered if medically necessary. General nursing care. Covers private duty nursing when medically necessary. Private duty nursing must be certified by specialist and PCP and approved in advance by Aetna/US Healthcare Medical Director. Intensive or special care facilities when medically necessary. X-rays, including CAT scans. Operating room and related facilities. This includes pre and post operative care, anesthesia and anesthesia services. MRI. Drugs, medications and biologicals when medically necessary. Cardiography/encephalograpy. Laboratory testing and services. Special tests when medically necessary. Nuclear medicine. Oxygen and oxygen therapy. Intravenous injections and solutions. Surgical, medical and obstetrical services. Cost Sharing: Copayment applies. Excludes: Dental x-rays, experimental or investigational transplants.
Outpatient Services		Covers: Specialist services at participating hospital outpatient departments during office or business hours upon prior written referral by PCP.
Emergency Care		Within and outside service areas, at participating and non-participating facilities: Covers services for symptoms which Aetna/US Healthcare’s medical review determines to have been severe, which occurred suddenly and for which a member sought immediate medical attention. Limits: Aetna/US Healthcare will reimburse member for reasonable cost as determined by Aetna/US Healthcare by non-participating providers without prior written referral only if: the service rendered is provided as a benefit under this certificate, and The PCP is notified within 48 hours or by the end of the first business day following the emergency service. Aetna/US Healthcare must be furnished with written proof of the occurrence, nature and extent of the emergency within 30 days of the date of services. Failure to immediately notify or to furnish written proof within 30 days will not invalidate or reduce any claim for reimbursement if Aetna/US Healthcare determines that the member’s failure to do so was reasonable under the circumstances. However, no reimbursement shall be made until Aetna/US Healthcare receives proper written proof. Aetna/US Healthcare may limit reimbursement for emergency services by a non-participating provider to expenses incurred up to the time the member is determined to be medically able to travel or to be transported to a participating provider. Cost Sharing: Member is responsible for a copayment for each emergency visit to a physician’s office or hospital outpatient department or emergency room. The copayment for an emergency room visit will not apply if the member was referred by his/her PCP for services that should have been provided in the PCP’s office.
Urgent Care		Covered outside service area.
Ambulance		Covers: Ambulance service in an emergency or when certified as medically necessary by PCP and approved in advance by Aetna/US Healthcare. Also covers transportation from a non-participating provider to a participating provider when medically necessary. Aetna/US Healthcare will reimburse member for the reasonable cost.
Care for Students Outside of Service Area	Not listed in Evidence of Coverage.
Non-Urgent Care Outside Service Area		Not covered.
Professional Services
Professional Services (general)		Primary care services: Covers office visits during office hours and during non-office hours when medically necessary. Covers home visits by PCP when medically necessary; casts and dressings; and emergency care. Specialty care services: Covered if provided by participating specialist physician at the provider’s office or at a participating hospital outpatient department during office or business hours upon prior written referral by PCP. Cost Sharing: Copayment may apply.
OB/GYN		Covers: OB/GYN services for female members 13 years of age or older. referral not required for services of participating OB/GYN for care related to the female reproductive system.
Diagnostic Procedures		Covers: Lab and x-ray, EKGs, and other diagnostic services when medically necessary and prescribed by a participating physician.
Therapeutic Treatment Services		Covers: radiation, chemo-therapy, respiratory therapy Cost Sharing: Copayments may apply.
Allergy Testing		Covered.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Well child care, routine physicals, ear, hearing and eye examinations. Excludes: Special medical reports no directly related to treatment of the member, e.g., employment or insurance physicals, reports prepared in connection with litigation.
Immunizations		Covers: Recommended children’s immunizations and other medically necessary immunizations. Excludes: immunizations for the purpose of travel or employment.
Preventive Clinical Services		Covers: Pap smears, mammograms, and PSA tests (as required in state law).
Other Health Promotion/Disease Prevention Activities		Covers: Health education and health care information literature at HMO’s discretion. Cost Sharing: A small charge applies for some materials.
Diabetic Treatment		Complies with new laws.
Conception Services
Prenatal Care and Obstetrical Services		Covers: Prenatal and other obstetrical services, including a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean section. Member may elect to be discharged earlier when medically appropriate. Cost Sharing: Copayment applies.
Family Planning		Covers: referral to family planning services, and referral to and payment for services of appropriate agencies as necessary. Excludes: Norplant and other implanted birth control devices such as IUDs, diaphragms, condoms, and contraception drugs.
Abortion		Covered. Cost Sharing: Applicable hospital copays apply.
Infertility Services		Covers: Diagnosis and treatment of infertility for subscriber, his/her covered spouse, and/or other covered dependent. Services must be rendered in a provider’s office or hospital. Cost Sharing: Copayment applies. Excludes: Infertility injectable medications and drugs related to the treatment of infertility. Also excludes charges for freezing and storage of cryopreserved embryos, charges for storage of sperm, donor costs (eggs and sperm) and costs for ovulation predictor kits. Reversal of voluntary sterilization and related follow-up care are also excluded.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Covers: Up to 35 days for the treatment of mental or nervous disorders per calendar year upon referral by PCP or if provided or arranged for by the participating mental health provider. Cost Sharing: Copayment applies. Excludes: Treatment of mental retardation, defects and deficiencies. Covers referral to family counseling services, but not payment for services.
Mental Health Outpatient		Covers: Up to 20 visits per calendar year. This includes individual, group or family therapy sessions for services appropriate for short-term evaluation or crisis intervention, mental health services or both. Limits: Referral by PCP to participating mental health provider is required. Member may exchange one mental health inpatient benefit for up to 4 outpatient visits. Member may exchange up to a maximum of 10 inpatient days for a maximum of 40 additional outpatient visits. Member may exchange one inpatient day for 2 days of treatment in a partial hospitalization program in lieu of hospitalization up to the maximum benefit limitation upon approval by HMO. Requests for benefit exchange must be initiated by the member’s mental health provider and approved in advance by Aetna/US Healthcare. Member must use all outpatient mental health benefits available under the certificate and pay all applicable copayments before an exchange will be considered. Cost Sharing: Copayment applies Excludes: Treatment of mental retardation, defects and deficiencies. Covers referral to family counseling services but not payment for services.
Substance Abuse Inpatient		Covers: Inpatient services for detoxification and treatment. Cost Sharing: copayment applies. Excludes: Chronic alcoholism or drug addiction treatment.
Substance Abuse Outpatient		Covers: Diagnosis, medical treatment and medical referral services by PCP for the abuse of or addiction to alcohol or drugs. Cost Sharing: Copayment applies. Excludes: Chronic alcoholism or drug addiction treatment.
Prescription Drugs and Medical Supplies
Prescription Drugs		Covers: Drugs appropriate to the member’s needs or condition for covered services, prescribed by a participating provider and approved in advance of treatment by HMO. Inpatient hospital, skilled nursing facility and inpatient substance abuse medications. Includes injectables when an oral alternative drug is not available. Off-label use of medications for certain types of cancer, in accordance with state law. Limits: Member must obtain covered medications at a participating pharmacy. Cost Sharing: Copayments apply. Excludes: Experimental or investigational drugs/medications that have not been proven safe and effective for a specific disease or approved for a mode of treatment by the FDA and the NIH. Off-label use of injectable drugs unless for cancer treatment. However, any drug which the FDA has determined to be contra-indicated for treatment of the specific type of cancer for which the drug has been prescribed is excluded. Drugs related to the treatment of infertility. Contraceptives. Performance enhancing steroids.
Blood		Covers: Administration and processing of blood. Excludes: Provision of blood, blood plasma, blood derivatives or the cost of receiving the services of professional blood donors.
Medical Supplies		Covers: Casts and dressings; needles, syringes, injectable supplies for diabetes. Excludes: False teeth, arch supports, elastic hose, cervical collars, corsets, wigs or cranial prosthesis, diapers, canes, crutches, special appliances, supplies or equipment and other DME.
Insulin and Diabetic Supplies		Covered in accordance with new laws.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment		Excludes: Braces, TENS (Transcutaneous Electrical Nerve Stimulation) units, traction apparatus, walkers, wheelchairs, special appliances, supplies or equipment and other DME.
Prosthetics		Covers: Artificial aids such as cardiac pacemakers, artificial heart valves, initial corrective lenses following cataract surgery. Also covers initial provision of prosthetic appliance used to treat congenital defects. Limits: Precertification required.
Orthotics		Covers: Orthopedic braces, with shoes when necessary, used to treat congenital defects. Excludes: Corrective shoes.
Rehabilitative and Habilitative Services
Physical Therapy		Covers: Physical therapy for non-chronic conditions, illnesses and injuries. Limits: Covers treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna/US Healthcare. Cost Sharing: Copayment applies.
Occupational Therapy		Covers: Occupational therapy for non-chronic conditions, illnesses and injuries. Limits: Covers treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna/US Healthcare. Cost Sharing: Copayment applies Excludes: Vocational rehabilitation or employment counseling.
Speech Therapy		Covers: Speech therapy for non-chronic conditions, illnesses and injuries. Limits: Covers treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna/US Healthcare. Cost Sharing: Copayment applies
Pulmonary Therapy		Covers: Pulmonary rehabilitation as part of an inpatient hospital stay.
Chiropractic		Covers: Manipulative services provided by participating osteopathic physicians upon referral from PCP. Also covers services provided by an osteopathic physician who the member’s PCP.
Cardiac Rehabilitation		Covers: Cardiac rehabilitation as part of an inpatient hospital stay.
Other Therapy Services		Cognitive Therapy. Covers treatment for a 60 day period per incident of illness or injury beginning with the first day of treatment for non-chronic conditions, acute illnesses and injuries. This must be part of a treatment plan coordinated with the HMO upon referral by PCP and upon approval by HMO. Cost Sharing: Copayment applies.
Skilled Nursing Facility		Covers: medically necessary services which constitute skilled nursing care as defined by the Medicare law. Cost Sharing: Inpatient copayment (if any) applies. Excludes: Custodial or other care that does not require the continuing attention of trained medical or paramedical personnel.
Home-Based Services
Home Health		Covers: Skilled nursing services for a homebound member. Treatment must be provided by or supervised by an RN. Services of a home health aide when the purpose of the treatment is skilled care. Treatment must be supervised by an RN. Medical social services provided along with other home health services. The PCP must certify that such services are necessary for the treatment of member’s medical condition. Limits: Services must be provided by a home health agency in lieu of a hospitalization. In addition, services must be approved and arranged in advance by HMO. HMO shall not be required to provide home health benefits when it determines the treatment setting is not appropriate or when there is a more cost effective setting in which to provide appropriate care. Excludes: Custodial or care that does not require the continuing attention of trained medical or paramedical personnel.
Private Duty Nursing		Covers: Private duty nursing approved by the HMO under home health, hospice or inpatient care. Note: Must be medically necessary and certified by participating specialist, approved by the PCP and approved in advance by Aetna/US Healthcare.
Hospice		Covers: Hospice for terminally ill member with life expectancy of 6 months or less. Includes home and hospital visits by nurses and social workers, pain management and symptom control. Also includes instruction for family members, inpatient care, counseling and emotional support, and other home health benefits listed in home health section.
Transplants and Dialysis
Transplants		Covers: Non-experimental transplants, including the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program. A transplant is non-experimental when HMO determines that the majority of physicians who are board certified in the appropriate specialty consider the procedure appropriate for the specific condition of the member. Also covers travel and lodging expenses for the member and for the parent or guardian when accompanying a minor for a transplant procedure outside the service area. Limits: Transplant must be ordered in writing by HMO in advance of surgery, and performed at hospitals specifically approved and designated by HMO to perform these procedures. Excludes: Experimental or investigational transplants.
Dialysis		Covered.
Other Services
Dental		Covers: Oral surgery, limited to bony impactions of teeth, bone fractures, removal of tumors and orthodontogenic cysts or other HMO/NC pre-approved surgical procedures. Covered treatment for temporomandibular join dysfunction includes pre-authorized therapeutic procedures, splinting and the use of introral prosthetic appliances when medically necessary and approved by HMO. Limits: Non-surgical treatment of TMJ shall be limited to $3500 per member per lifetime. Excludes: Dental x-rays All dental services related to the care, filling, removal or replacement of teeth. Treatment of injuries to or diseases of the teeth and gums, including but not limited to apicoectomy (dental root resection). Orthodontics. Root canal treatment. Soft tissue impactions. Alveolectomy. Treatment of periodontal disease. Dental implants.
Vision		Covers: Routine eye examination by PCP; initial corrective lenses following cataract surgery. Excludes: Radial keritotomy and related procedures designed to surgically correct refractive errors. Also excludes orthoptics which are eye exercises designed to correct eye problems.
Hearing		Covers: Ear and hearing examinations by PCP. Excludes: Hearing aids.
Foot Care		Covers: Medically necessary reduction of nails, calluses and corns.
Weight Loss		Covers: Weight reduction programs provided by HMO. Excludes: Dietary supplements, surgical operations or procedures for treatment of obesity such as gastric stapling or balloon procedures.
Smoking Cessation		Not listed in Evidence of Coverage.
Growth Hormones		Not listed in Evidence of Coverage.
Alternative Therapies		Excludes: Acupuncture, thermography (a diagnostic technique using an infrared camera to measure temperature variations on the surface of the body)
Reconstructive/Cosmetic Surgery		Covers: Surgeries to correct the results of injuries or congenital defects necessary to restore normal bodily functions including but not limited to cleft lip and cleft palate. Also covers breast reconstruction following mastectomy. Excludes: Cosmetic surgery such as ear piercing, rhinoplasty, lipectomy, and surgery or treatment relating to the consequences or as a result of cosmetic surgery other than medically necessary services. Also excludes treatment of gynecomastia (abnormal enlargement of male mammary glands) and augmentation or reduction mammoplasty.
Non-Emergency Transportation		Covers: Transportation from a non-participating provider to a participating provider will also be covered when medically necessary. Travel expenses are covered for the member and for the parent or guardian when accompanying a minor for a transplant procedure outside the service area.
Excluded Services
Experimental or Investigational Services		Excluded.
Services Not Considered Medically Necessary		Excluded.
Non-Emergency Services Rendered in Emergency Room		Excluded.
Commonly Excluded Services		See list of common exclusions.
Definitions
Medically Necessary		Statutory definition.
Experimental or Investigational		Not defined in definition section. Defined in transplant section as: A transplant is non-experimental, non-investigational when the HMO determined, that the "medical community" has accepted the procedure as appropriate treatment for the member’s condition. The "medical community" constitutes the majority of physicians who are board certified in the specialty.
Emergency		Follows statutory definition of emergency..
Urgent Care		Not listed in Evidence of Coverage.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider		General, family care practitioner; in some cases internist, pediatrician.
What Happens if Member Fails to Choose a PCP?		Member is encouraged to select a PCP.
Process to Change PCP		Call member services; no limits to number of changes
Referrals to Specialists		Referrals to participating specialists: Requires prior written referral by PCP. referrals to non-participating specialists: Excluded. Services are available only from participating providers except in cases of emergency,
Can Specialists Serve as PCP?		No.
Non-Emergency Hospital Preauthorization Requirements		Participating hospitals: Member must be hospitalized by a participating physician upon prior written referral from PCP, and precertified by HMO. Non-participating hospitals: Requires prior written authorization by HMO.
Appeal and Grievance Procedures
Informal Reconsideration		No procedure listed in the Evidence of Coverage.
First-Level Non-Certification Appeal Provisions		Follows statutory definition. Note: Time limits for the filing of an appeal or grievance and member notification of decision are not listed in the Evidence of Coverage.
First-Level Expedited appeals		Follows statutory definition. Note: Time limits for the filing of an appeal or grievance and member notification of decision are not listed in the Evidence of Coverage.
First-Level Grievance Hearings		Follows statutory definition. Note: Time limits for the filing of an appeal or grievance and member notification of decision are not listed in the Evidence of Coverage.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)		Follows statutory definition. Note: Time limits for the filing of an appeal or grievance and member notification of decision are not listed in the Evidence of Coverage.
Second-Level Expedited Appeals		Follows statutory definition. Note: Time limits for the filing of an appeal or grievance and member notification of decision are not listed in the Evidence of Coverage.
Other Avenues of Appeal		Members can obtain independent information about the appeals process, and seek assistance from the NC Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes		Members have the right to have an uninvolved HMO representative assist them in understanding the grievance process. In the appeals process, due consideration shall be given to the availability or non-availability of optional health care services proposed by the HMO and any hardship imposed by the optional health care on the patient and his/her immediate family. The appeals process does not apply to any noncertification rendered solely on the basis that a health benefit plan does not provide benefits for the health care performed or being requested.
Enrollment Trends
Enrollment on December 31, 1998 (Financial Report, # 10)	37,417
Member Months in 1998 (Financial Report, #11)	357,317
Average 1998 Monthly Enrollment (Member Months/12)	29,776
Percentage Change in Average Monthly Enrollment between 1997-1998	111.5%
Five-year Enrollment Trends	1998: 29,776 1997: 14,081 1996: 3,062 1995: N/A 1994: N/A
Percentage of Groups that Disenrolled (December 31, 1997-December 31, 1998)	NA1
Percentage of Members that Disenrolled (December 31, 1997-December 31, 1998)	NA1
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1997 — Dec. 31, 1998)	6%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1997 — Dec. 31, 1998)	0.4%
Utilization Review Information
Number of. Reviews Requested, 1998	9,023
Review Rate Per 1,000 Members, 1998	454
Percentage of Noncertifications, 1998	1.55%
Noncertification Rates per 1,000 Members	7.05
Appeal rate per 1,000 Noncertifications, 1998	135.71
Percentage of Appeals Decided for the Members, 1998	68.42%
Financial Data
Total 1998 Revenues (Financial Report, #6)	$40,320,315
Total Premium per member per month (Financial Report, #5 / #11), 1998	$111.25
Five-Year Premium per member per month Trends	1998: $111.25 1997: $98.70 1996: $99.17 1995: N/A 1994: N/A
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1998	$110.56
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1998	99.4%
Five-Year Medical Loss Ratio Trends	1998: 99.4% 1997: 98.8% 1996: 126.8% 1995: N/A 1994: N/A
Operating Profit Margin (Financial Report, #9 / #6), 1998	(13.5%)
Operating Profit Margin Trends	1998: (13.5%) 1997: (15.9%) 1996: (134%) 1995: N/A 1994: N/A
Sources of Information
Source of Information	U.S. Healthcare of the Carolinas, Inc, Certificate of Coverage, HMO/NC CERT-1 (10/95); 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on utilization review and Appeals and Grievances from NC DOI .

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