CIGNA HEALTHCARE OF NORTH CAROLINA, INC.
Updated 11/00

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

HMO General Information
Background Information	Cigna Healthcare of North Carolina, Inc. North Carolina received its HMO license from the NC Department of Insurance on April 18, 1986 and commenced business that same day. Cigna Healthcare of North Carolina, Inc. is a for-profit corporation. It is owned by Cigna Corporation, a Delaware corporation.
Type of HMO	Cigna Healthcare of North Carolina, Inc. operates an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Type of Products	Cigna Healthcare of North Carolina, Inc.’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. Cigna Healthcare of North Carolina, Inc. also offers a point-of-service option and recently began marketing an open access HMO/POS product.
Accreditation	Cigna Healthcare of North Carolina, Inc. received a commendable accreditation from the National Committee for Quality Assurance (NCQA). NCQA looks at five categories in its accreditation process access and services, qualified providers, staying healthy, getting better, and living with illness. An HMO seeking accreditation is evaluated on how well it meets NCQA’s standards in each of these areas. HMOs that fully meet NCQA’s standards receive a Commendable status. Those that meet most of NCQA standards receive an Accredited status. Provisional accreditation may be given for plans that meet some, but not all, of NCQA standards. Health plans that fail to meet NCQA’s requirements during the review will have their accreditation request Denied. A health plan’s accreditation status gives an idea of the quality of care provided by the plan as a whole. However, NCQA’s accreditation does not guarantee the quality of care provided to any individual member.
Enrollees	Cigna Healthcare of North Carolina, Inc. 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	Cigna Healthcare of North Carolina, Inc. has at least 25 HMO members in the following North Carolina counties at the end of 1999: Alamance, Alexander, Anson, Beaufort, Bladen, Brunswick, Buncombe, Burke, Cabarrus, Caldwell, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus, Craven, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Iredell, Jackson, Johnston, Jones, Lee, Lenoir, Lincoln, Madison, Martin, McDowell, Mecklenburg, Montgomery, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pender, Perquimans, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Rutherford, Sampson, Scotland, Stanley, Stokes, Surry, Transylvania, Union, Vance, Wake, Warren, Washington, Wayne, Wilkes, Wilson, and Yancey.
Customer Service Number	1-800-849-9000
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services	Covers: Semiprivate room and board. (Private room covered when medically necessary). Hospital ancillary services; facility fees. Drugs and medications while confined as an inpatient; blood transfusion services. Intensive and step down care. Provider/professional charges. Rehabilitative hospitals when requested by a participating provider. Limits: Prior approval required for non-emergency admissions. Cost Sharing: Copayments may apply.
Outpatient services	See inpatient services.
Emergency care	Covers: Emergency services within service area. If members believe that an emergency exists, they should proceed to the nearest emergency care facility or dial 911 as appropriate. In an emergency, members are not required to obtain preauthorization, notify CHCNC that emergency services will be or have been utilized, or use in-plan facilities Emergency services outside service area. Healthsource will cover emergency care when medically necessary for members. Coverage includes students away at school, and members on vacation. For all emergency services: Care received in an emergency room must meet CHCNC’s emergency definition. HealthSource applies the prudent lay person language to its definition of an emergency. CHCNC will provide coverage for emergency services until the condition is stabilized. If the member is admitted, the emergency room copayment will be waived. Follow-up care is covered if provided by a member’s PCP or a Consulting Specialist, with referral from a PCP and prior authorization. Follow-up services only covered if provided by PCP, or upon referral of PCP and authorization by CHCNC. Notification Requirements: After an emergency condition is stabilized, member must notify CHCNC of continued treatment. Notify your PCP as soon as reasonably possible, considering the member’s medical condition. If notification is not received, the services may not be covered. Excludes: CHCNC will not cover emergency services which could have been foreseen before leaving the immediate area, including, but not limited to, delivery beyond 35th week of pregnancy, dialysis, scheduled medical treatment, or therapy or upon physician recommendation that the member should not travel due to their medical condition.
Urgent Care	Within Service Area: Same procedure as emergency services, when provided by an in-plan urgent care facility, or by a member's PCP or a consulting specialist with referral from a PCP. Services Outside of Service Area: CHCNC will cover urgent care when medically necessary, including urgent care for students away at school, and members on vacation. urgent care received at any facility must meet CHCNC’s definition of urgent care for services to be covered.
Ambulance	Covers: Ambulance in an emergency when medically necessary. Members should dial 911 to access this service. If 911 services are unavailable, members should contact the nearest Emergency care facility.
Care for Students Outside of Service Area	Covers: Emergency care meeting a prudent layperson definition or urgent care meeting the plan definition only.
Non-Urgent Care Outside of Service Area	Excluded.
Professional Services
Professional Services (general)	Covers: PCP and OB/GYN office services; consulting specialist office services; after-hours office visits (an additional copayment will apply). Also covers medications that cannot be home- or self-administered. Limits: Prior authorization by CHCNC is required for all new drugs or products approved by the Food and Drug Administration (FDA) after January 1, 1997.
OB/GYN	Covers: Services of OB/GYN for care related to the female reproductive system. Referral not required.
Diagnostic Procedures	Covers: Medical diagnostic services; X-ray and laboratory services. Limits: Magnetic Resonance Imaging (MRI) scans require prior authorization.
Therapeutic Treatment Services	Covers: Radiation, Chemo-Therapy, Respiratory Therapy
Allergy Testing	Covered.
Preventive Services
Annual Physicals (well-baby, well-child)	Covers: Well child care and physical examinations. Excludes: Routine physical exams and testing required for marriage, or by third parties, such as schools, employers, athletic teams or judicial bodies.. Also excludes exams and vaccinations required to travel abroad.
Immunizations	Covered.
Preventive Clinical Services	Covers: Pap smears, mammograms, and PSA tests (as required in state law).
Other Health Promotion/Disease Prevention Activities	Covers: Health education programs provided by CHCNC.
Diabetic Treatment	Covers: Medically necessary outpatient self-management training and education. Treatment and education are covered for diabetic medications and supplies in accordance with the state requirements. Diabetic medications and supplies are covered with or without a drug supplemental policy. Copayment may apply. Limits: Outpatient facility self-management programs require prior approval.
Conception Services
Prenatal Care and Obstetrical Services.	Covers: Prenatal and obstetrical services, including a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean sections.
Family Planning	Covers: Prescribed contraceptive devices, diaphragms, IUDs, Norplant and Depo-Provera with copayments. Also covers vasectomies and tubal ligations Limits: Prior authorization for Norplant and Depo-Provera is unnecessary if received from the gynecologist’s office services. Prior authorization is required for tubal ligations and vasectomies. Cost Sharing: Copayments apply.
Abortion	Covered. Cost Sharing: Copayment applies
Infertility Services	Excludes: Diagnosis or treatment of infertility, unless covered through a supplemental policy. An office visit will be covered if infertility is a secondary or incidental diagnosis and no treatment of diagnosis testing for infertility was performed.
Mental Health and Substance Abuse Services
Mental Health Inpatient	Excluded, unless purchased in a supplemental policy. With the purchase of a supplemental policy-- Covers: Inpatient services provided by Cigna Behavioral Health, Inc., a specialized managed care organization that provides mental health and substance abuse services. Also covers care in day treatment facilities. Emergency services are available 24 hours a day. Limits: Members must obtain pre-authorization from CBH in order for services to be paid. Inpatient care is approved only when the physician determines that outpatient treatment is not appropriate. Coverage is limited to short-term therapy medically necessary for diagnosis, crisis intervention, and treatment of mental health conditions. Day/Visit limits also apply based on the benefit supplemental policy purchased. Cost-sharing: Copayments apply based on the benefit supplemental policy purchased. Excludes: Evaluation and treatment of learning disabilities, delayed speech and stuttering.
Mental Health Outpatient	Excluded, unless purchased in a supplemental policy. With the purchase of a supplemental policy-- Covers: Outpatient services provided by Cigna Behavioral Health, Inc. (see inpatient services). Emergency services are available 24 hours a day. Limits: Outpatient care is preferred and is approved for up to 30 visits per year. Coverage is limited to short-term therapy medically necessary for diagnosis, crisis intervention, and treatment of mental health conditions. Member must obtain pre-authorization from Cigna Behavioral Health, Inc. in order for services to be paid. Day/Visit limits also apply based on the benefit supplemental policy purchased. Cost-sharing: Copayments apply based on the benefit supplemental policy purchased.
Substance Abuse Inpatient	Excluded, unless purchased in a supplemental policy. With the purchase of a supplemental policy-- Covers: Inpatient services provided by Cigna Behavioral Health, Inc., a specialized managed care organization that provides mental health and substance abuse services. Also covers some day treatment services. Emergency services are available 24 hours a day. Limits: Inpatient care is approved only when the physician determines that outpatient treatment is not inappropriate. Coverage is limited to short-term therapy that is medically necessary to provide diagnosis, crisis intervention, and treatment of substance
Substance Abuse Outpatient	Excluded, unless purchased in a supplemental policy. With the purchase of a supplemental policy-- Covers: Outpatient substance abuse services provided by Cigna Behavioral Health, Inc., a specialized managed care organization that provides mental health and substance abuse services. Also covers intensive outpatient care. Emergency services are available 24 hours a day. Limits: Outpatient care is the preferred mode of treatment. Coverage is limited to short-term therapy that is medically necessary to provide diagnosis, crisis intervention, and treatment of substance abuse conditions. Visit and/or benefit limitation.
Prescription Drugs and Medical Supplies
Prescription drugs	Covers: Medication used in treatment of diabetes or prescription contraceptive devices. Other prescription drugs are not always covered. However, most CHCNC plans cover generic drugs, brand name drugs, nonpreferred blood glucose test strips, nonpreferred blood glucose test strips, and insulin syringes. Excludes: Other prescription drugs except when specifically purchased through supplemental policies.
Blood	Covers: Blood transfusion. Excludes: Blood. Limits: Prior authorization required. Cost Sharing: Copays apply.
Medical Supplies	Covers: Non-durable medical supplies from a participating provider’s office or by an approved home health care agency for the treatment of a specific medical condition. Limits: Maximum benefit applies. Cost Sharing: Copayment applies. Excludes: Medical supplies, such as, but not limited to, bandages, cotton gauze, hot or cold packs, syringes and needles (except for insulin syringes and all diabetic supplies).
Insulin and Diabetic Supplies	Covers: Equipment, supplies, medications, and laboratory procedures needed to treat diabetes. Limits: Diabetic equipment requires prior authorization.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)	Covers: Durable medical equipment. Limits: CHCNC reserves the right to determine whether rental or purchase is more appropriate. Repair and replacement of these items are covered with prior authorization when requested by a participating provider. Maximum benefit applies. Cost Sharing: Copayment applies. Coverage of customized DME: Not listed in Evidence of Coverage. Excludes: Non-durable goods for use with a durable medical equipment item; repair or replacements when due to misuse or loss.
Prosthetic Devices	Covers: Prosthetic appliances. CHCNC reserves the right to determine whether rental or purchase is more appropriate. Limits: Repair and replacement of these items are covered with prior authorization when requested by a participating provider. Maximum benefit applies. Cost Sharing: Copayment applies. Excludes: Repair or replacements when due to misuse or loss.
Orthotic Devices	Covers: Orthotic devices, if medically necessary, and requested by a medical doctor. Excludes: Orthotic devices to treat fallen arches.
Rehabilitative and Habilitative Services
Physical therapy	Covers: Short-term services for conditions that are expected to show significant improvement within a 60-day period, as determined by CHCNC. Limits: Visit limits apply. Cost Sharing: Copayment applies.
Occupational therapy	Covers: Short-term services for conditions that are expected to show significant improvement within a 60-day period, as determined by CHCNC. Limits: Visit limits apply. Cost Sharing: Copayment applies.
Speech Therapy	Covers: Conditions that are expected to show significant improvement within a 60-day period, as determined by CHCNC. Covered for correcting speech disorders that are the result of diagnosed medical illness, surgery or accidents only. Limits: Visit limits apply. Cost Sharing: Copayment applies.
Pulmonary Therapy	Covers: Covers pulmonary therapy. Cost Sharing: Copayment applies.
Chiropractic	Excludes: Spinal manipulations unless covered by a supplemental policy.
Cardiac Rehabilitation	Covered. Cost Sharing: Copayment applies.
Other Therapy Services	Excludes: Pain therapy, family therapy, sex therapy, or recreation therapy unless covered on a mental health rider.
Skilled Nursing Facility	Covers: Skilled nursing facility in a participating facility when requested by a participating provider. Limits: Visit limits apply.
Home-Based Services
Home Health	Covers: Short-term home health care and skilled nursing services. Limits: Visit limits apply. Excludes: meals, housekeeping and personal convenience or comfort items.
Private Duty Nursing	Covers: Private duty nursing on a case-by-case basis when determined to be appropriate by CHCNC.
Hospice	Covered. Excludes: meals, housekeeping and personal convenience or comfort items.
Transplants and Dialysis
Transplants	Covers: medically necessary organ, bone marrow or stem cell transplants. Limits: Services must be approved by CHCNC and performed in an approved transplant center. Not all participating facilities are approved transplant centers. Donor expenses: Covers donor expenses, including expenses to locate a donor and/or diagnostic and pre-transplant care for the donor. Limit of $10,000 for donor expenses. This limit does not include transportation, lodging or meal expenses. CHCNC will coordinate coverage for donor expenses with the donor’s health insurance ("coordination of benefits").
Dialysis	Covered.
Other Services
Dental	Covers: Repairs as a result of accidental injury to sound, natural, permanent, adult teeth for up to 12 months from the date of injury. Treatment must begin within 48 hours of injury. Follow-up care is covered only if provided by a member’s PCP or consulting specialist or nonparticipating provider with referral from a PCP and prior authorization. Evaluation and treatment of TMJ dysfunction when it results from congenital deformity, disease or accident. Cost Sharing: Copayments apply. Excludes: routine dental care or any oral evaluation (including splints and intraoral appliances), treatment or surgery not specifically covered. Orthodontic braces, crowns, bridges, dentures, dental root form implants, root canals and other similar dental services are not covered. Nor are injuries that occur when chewing or biting.
Vision	Excluded, unless purchased in a supplemental policy. With the purchase of a supplemental policy, covers: Routine eye examination by participating opthalmologist or optometrist. No referral is necessary. Also includes $50 hardware allowance for lenses, frames, or contacts. Excludes: Some supplemental policies do not cover lenses, frames, or contacts.
Hearing	Covers: Excluded, unless purchased in a supplemental policy. With purchase of a supplemental policy, covers: expense of fitting and purchase of one hearing aid her ear. Cost-sharing: Durable medical equipment copay will apply.
Foot Care	Covers: Foot care for members with a diabetes diagnosis that is medically necessary. Limits: Prior authorization may be necessary. Excludes: Foot care for routine nail cutting, corns, calluses, flat feet, fallen arches, weak feet or chronic foot strain.
Weight Loss	Excludes: Any care that is primarily for weight loss, or for any surgical treatment of obesity. Also excludes drugs and therapies (treatments) used for the purpose of weight loss, dietary supplements, liposuction, abdominoplobly gastic bypass and wiring of jaws.
Smoking Cessation	Excluded
Growth Hormones	Covers: Human growth therapy. Limits: Visit limits apply. Cost Sharing: Copayment applies. Excludes: Treatment for short stature only.
Alternative Therapies	Covers: Medical biofeedback treatment. Limits: Visit limits apply. Cost Sharing: Copayment applies.
Reconstructive/Cosmetic Surgery	Covers: Reconstructive breast surgery following mastectomy. Includes coverage for all stages and revisions of reconstructive breast surgery performed on nondiseased breast to establish symmetry. Also covered when surgery will restore normal functioning that was impaired by disease, trauma or congenital abnormalities, including delayed surgery for minor children for condition cleft lip or cleft palate.
Non-Emergency Transportation	Covers: Travel and lodging when Healthsource refers a patient to a medical facility outside the service area because services were not available through a par provider Limits: Advanced approval required. Excludes: Travel expenses for organ transplant donors.
Excluded Services
Experimental or Investigational Services	Excluded.
Services Not Considered Medically Necessary	Excluded. CHCNC also excludes services that do not meet coverage criteria (separate from medical necessity).
Non-emergency services Rendered in Emergency Room	Excluded.
Commonly excluded services	See list of common exclusions.
Definitions
Medically Necessary	Definition of medically necessary follows statutory definition.
Experimental or Investigational	Health interventions, including services, drugs, biologicals, medications, devices, or treatments, may be considered experiment or investigational if: At the time of the member’s request, there is not sufficient evidence to draw conclusions about the health intervention’s effects on the outcomes. The evidence does not show that the health intervention is expected to produce its intended health outcomes. Studies have shown that the proposed health intervention’s adverse effects outweigh the health intervention’s expected beneficial effects. Note: It is not relevant for purposes of determining whether a procedure or treatment is covered under this provision that the member has tried other more conventional therapies without success.
Emergency	Follows statutory definition.
Urgent Care	A medical condition that occurs suddenly and unexpectedly, requiring prompt diagnosis and treatment or the individual could reasonably be expected to suffer an extended illness, prolonged impairment or require a more hazardous treatment. Minor wounds requiring stitches, muscle strains, and ear aches are examples.
OTHER	Coverage criteria includes the following: Health intervention is used for a medical condition; Sufficient evidence exists to draw conclusions about the intervention’s effects on health ; Evidence demonstrates that the intervention can be expected to produce its intended effects on health outcomes; Intervention’s expected beneficial effects on health outcomes outweigh its expected harmful effects; Intervention is the most cost-effective methods available to address the medical condition; and Intervention satisfies Doctors’ medical criteria for the particular member’s medical condition.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider	PCPs can be in the specialties of Internal Medicine, Family Practice, Pediatrics and General Practice.
What Happens if Member Fails to Choose a PCP?	If you do not select a PCP, whoever you go to first will be assigned to you as your PCP.
Process to Change PCP	You may change your PCP by calling CHCNC’s Member Services Department. CHCNC allows members to change their PCP once per month.
Referrals to Specialists	If a member’s PCP cannot provide care, s/he will refer the member to a Consulting Specialist. A CHCNC participating provider may request that CHCNC approve a referral to a non-participating provider. CHCNC will cover such services only if they are not available from a participating provider. CHCNC must approve the referral in advance and in writing. CHCNC may direct members to a particular nonparticipating provider or facility. Referrals are not needed for female health services of an OB/GYN.
Can Specialists Serve as PCP?	No.
Non-Emergency Hospital Preauthorization Requirements	You must obtain referral from your PCP and prior approval of CHCNC for non-emergency care.
Appeal and Grievance Procedures
Informal Reconsideration	Members and/or their representatives are encouraged to contact the CHCNC Member Services Department with concerns about claims, benefits or other issues. When informal resolution is not possible, or the member thinks it would not be helpful, members are encouraged to use the formal review process. Note: Time limits for the filing of an appeal and member notification of decision are not listed in the Evidence of Coverage.
First Level Non-Certification Appeal Provisions	Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to CHCNCwithin one year of the date of their noncertification. Members will receive a response from CHCNC within 30 days of CHCNC’s receipt of the appeal request.
First Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 72 hours of the receipt of all necessary information.
First Level grievance Hearings	Follows statutory definition. Note: Members or their representatives must file a grievance in writing within one year of the incident that caused the complaint. Members will be notified of the decision within 30 days of CHCNC’s receipt of their request for review.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)	Follows statutory definition. Note: Requests for second level grievance hearings must be made within one year of the first level appeal or grievance decision. The second level review meeting will be held within 45 days of the CHCNC receipt of a request for a second level grievance review. Member will be notified of the decision within 5 business days of the review meeting.
Second Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be communicated within four days of the receipt of all necessary information.
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	The appeal and grievance process does not apply to the following: Any decision based solely on the fact that CHCNC does not provide benefits for the health service performed or requested, as outlined in the Certificate. Disputes regarding the dollar amount by which benefits are limited or the number of visits covered, if those limitations are clearly stated in the policy. If a member fails to request an appeal within the appropriate time frames, the right to further appeal the matter may be waived. Members may request postponement of a scheduled hearing in the event of unavoidable circumstances, provided that CHCNC is given at least 48 hours advance notice.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)	170,281
Member months in 1999 (Financial Report, #11)	2,089,163
Average 1999 Monthly Enrollment (Member Months/12)	174,096
Percentage Change in Average Monthly Enrollment between 1998-1999	unavailable
Five-year Enrollment Trends	1999: 170,281 1998: 233,506 1997: 225,326 1996: 183,578 1995: 125,656
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)	23%
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)	17%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)	4%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)	<1.0%
Utilization Review Information
Number of Reviews Requested, 1999	78,217
Review Rate per 1,000 Members, 1998	unavailable
Percentage of Noncertifications, 1999	7.0%
Noncertification Rate per 1,000 Members, 1999	14.34
Appeal rate per 1,000 Noncertifications, 1999	69.04
Percentage of Appeals Decided for the Members, 1999	65.0%
Financial Data
Total 1999 revenues (Financial Report, #6)	$305,850,039
Average Premium per member per month (Financial Report, #5 / #11) 1999	$140.40
Five-Year Premium per member per month Trends	199: $140.40 1998: $130.92 1997: $126.12 1996: $125.18 1995: $131.45 1994: $130.68
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1999	$112.86
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1999	78.15%
Five-YearMedical Loss Ratio Trends	1998: 88.2% 1997: 90.3% 1996: 82.0% 1995: 76.7% 1994: 75.7%
Operating Profit Margin (Financial Report, #9 / #6), 1998	(.4%)
Five year operating profit margin trends	1998: (.4%) 1997: (2.0%) 1996: (2.7%) 1995: (8.2%) 1994: (14.4%)
Sources of Information
Source of Information	Evidence of Coverage: 400/0198; 1999 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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