DOCTORS HEALTH PLAN
Updated 10/2000

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

HMO General Information
Background Information	Doctors Health Plan received its HMO license from the NC Department of Insurance on September 30, 1994. It commenced business on October 1, 1994. Doctors Health Plan is a for-profit corporation, owned by Steven Scott, M.D.
Type of HMO	Doctors Health Plan 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	Doctors Health Plan’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. Doctors Health Plan also offers a point-of-service option, called "Universal Premiere Classic."
Accreditation	Doctors 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 Doctors Health Plan is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees	Doctors Health Plan 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	Doctors Health Plan had at least 25 commercial (group) HMO members in the following North Carolina counties at the end of 1999: Alamance, Bladen, Brunswick, Buncombe, Cabarrus, Carteret, Caswell, Catawba, Chatham, Cleveland, Columbus, Cumberland, Duplin, Durham, Edgecombe, Franklin, Gaston, Granville, Guilford, Halifax, Harnett, Iredell, Johnston, Lee, Lincoln, Mecklenburg, Montgomery, Moore, Nash, New Hanover, Onslow, Orange, Pender, Person, Pitt, Robeson, Rowan, Sampson, Union, Vance, Wake, Warren, Wayne, and Wilson.
Customer Service Number	1-877-855-3034
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: Room and board fees for a semi-private room (or private room when medically necessary). Hospital ancillary services (including use of operating room, anesthesia, laboratory, X-ray, and radiotherapy). Drugs and medications. Blood transfusion services. Intensive and step down care. Physician services, hospital staff nursing and intensive care. Limits: Requires precertification by Doctors. Does not cover private room charges that exceed the institution’s most common semi-private room charge, unless medically necessary or only accommodations available. Cost Sharing: Copayments may apply.
Outpatient services		Covers: Same services as for inpatient coverage. Limits: Requires prior authorization. Cost Sharing: Copayments may apply.
Emergency care		Covers: emergency services within the service area: Members should proceed to the nearest emergency care facility or dial 911. Members will not be required to obtain pre-authorization or use in-plan facilities in order to receive coverage for emergency services. Outside Service Area: Same as above, including for students at school and members on vacation. However, routine care and follow-up care must be provided by student’s PCP. Limits: Follow-up care is covered only if provided by the PCP or by a specialist if referred from a PCP and authorized by Doctors. Cost Sharing: Copayments may apply. Notification requirements: Members should notify Doctors of an emergency hospital admission as soon as reasonably possible to ensure payment of medical services. Excludes: Non-emergency use of emergency room or services which are not medically necessary.
Urgent Care		Covers: Same as emergency care. Cost Sharing: Copayments may apply.
Ambulance		Covers: Ambulance services when medically necessary.
Care for Students Outside of Service Area		Covers: Emergency or urgent care services only.
Non-Urgent Care Outside of Service Area		Excludes: Excluded unless the law mandates that the only reasonable treatment is outside the service area or unless a Point of Service rider is purchased.
Professional Services
Professional Services (general)		Covers: Provider, OB/GYN and consulting specialist office services. Limits: Specialist care requires referral from PCP. Cost Sharing: Copayments may apply.
OB/GYN		Covers: Services of OB/GYN for routine obstetric and gynecological care. Referral not required. Cost Sharing: Copayments may apply.
Diagnostic Procedures		Covered. Limits: MRI scans require prior authorization.
Therapeutic Treatment Services		Covers: radiation, chemo-therapy, respiratory therapy Limits/Cost Sharing: yes.
Allergy Testing		Covers: Allergy testing, serum and injections.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Well-child care; physical exams. Cost Sharing: Copayments may apply. Excludes: Physical examinations required by third parties such as insurers, schools, employers, camps, athletic teams or judicial bodies. Also excludes examinations required to travel abroad.
Immunizations		Covered. Excludes: Vaccinations required to travel abroad.
Preventive Clinical Services		Covers: Pap smears, mammograms, and PSA tests (as required by state law).
Other Health Promotion/Disease Prevention Activities		Covers: Health education programs provided by Doctors, health risk assessment, work site wellness, programs for healthy living and educational programs developed to support the medical management of certain conditions including diabetes and asthma.
Diabetic Treatment		Covers: Outpatient self-management training and educational services, equipment, supplies, medications and laboratory procedures used to treat diabetes. Limits: Outpatient facility self-management programs and educational services require prior authorization.
Conception Services
Prenatal Care and Obstetrical Services.		Covered. Cost Sharing: Pregnant member pays a one-time office copay for prenatal care. Mother’s and newborn’s charges for hospital and physician services are considered separate and will be considered separately for benefits under the benefit plan. Excludes: Genetic tests to determine paternity or sex of a child.
Family Planning		Covers: Vasectomies, tubal ligations, diaphragms, IUDs, Norplant, and Depo Provera. Cost Sharing: Copayments may apply.
Abortion		Covers: Abortions up to 12 weeks.
Infertility Services		Excludes: Treatment for infertility, including artificial insemination, and reversals of vasectomies and tubal ligations.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Covers: Mental health inpatient services. emergency services are available 24 hours a day. Referral from PCP is not necessary. Limits: Limited to 30 days per contract year. Care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422).
Mental Health Outpatient		Covers: Outpatient mental health services. emergency services are available 24 hours a day. Referral from PCP is not necessary. Limits: Limited to 20 visits per contract year. Care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422). Cost Sharing: Copayments may apply. Excludes: Treatment of mental retardation; mental evaluations required by third parties; marriage, family and child counseling.
Substance Abuse Inpatient		Excluded, unless purchased under a supplemental policy. emergency services are available 24 hours a day. Referral from PCP is not necessary. Limits: If covered, care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422). Substance abuse services are limited to an annual maximum of $8,000 per member and a lifetime maximum of $16,000. Cost Sharing: Copays may apply.
Substance Abuse Outpatient		Excluded, unless purchased under a supplemental policy. emergency services are available 24 hours a day. Referral from PCP is not necessary. Limits: If covered, care must be authorized and referred by Magellan Behavioral Health of North Carolina (1-800-359-2422). Substance abuse services are limited to an annual maximum of $8,000 per member and a lifetime maximum of $16,000. Cost Sharing: Copays may apply.
Prescription Drugs and Medical Supplies
Prescription drugs		Covers: Prescriptions during inpatient care. Outpatient prescriptions are excluded unless purchased under a supplemental policy. With purchase of a supplemental policy covers: Prescriptions filled by a participating pharmacy, unless an emergency. Doctors does not use a restrictive formulary. Limits: Doctors may limit the number of pills that may be filled at any one time. Cost Sharing: Copays apply. Excludes: Medications for cosmetic purposes or to enhance athletic performance. Drugs that are experimental. Replacement of lost or stolen medications. Drugs that do not require a prescription or that are substantially equivalent to an over the counter medication.
Blood		Excluded.
Medical Supplies		Covers: Non-durable medical supplies supplied in a participating provider’s office or by an approved home health care agency for the treatment of a specific medical condition. Limits: Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available.
Insulin and Diabetic Supplies		Covered.
Durable Medical Equipment, Prosthetics, and Orthotics
Prosthetic Devices		Covers: Prosthetics, including repair and replacement with prior authorization when requested by a participating provider. Limits: Doctors’ reserves the right to determine whether rental or purchase is more appropriate. Coverage for prosthetics requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available. Cost Sharing: Copayments may apply. Excludes: Repair or replacement of prosthetics needed because of misuse, normal wear, damage or loss.
Orthotic Devices		Excluded.
Durable Medical Equipment (DME)		Covers: DME, including repair and replacement. Limits: Must be requested by participating provider and approved in advance by the plan. Doctors’ reserves the right to determine whether rental or purchase is more appropriate. Must be provided by participating provider or facility unless there is no participating provider available. Excludes: Repairs and replacement if needed because of misuse or loss.
Rehabilitative and Habilitative Services
Physical therapy		Covers: Physical therapy for conditions expected to show significant improvement, as determined by Doctors Health Plan. Limits: Limited to 20 visits per illness per injury per contract year. Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available.
Occupational therapy		Covers: Occupational therapy for conditions expected to show significant improvement, as determined by Doctors Health Plan. Limits: Limited to 20 visits per illness per injury per contract year. Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available.
Speech Therapy		Covers: Speech therapy for conditions expected to show significant improvement, as determined by Doctors Health Plan. Includes coverage of therapy for correcting speech disorders that are the result of diagnosed medical illness, surgery or accidents only. Limits: Limited to 20 visits per illness per injury per contract year. Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available.
Pulmonary Therapy		Covered.
Chiropractic		Covers: Chiropractic services for a specific problem. Limited to 20 visits per illness or injury for conditions expected to show significant improvement within a 60 day period. Limits: Requires referral from PCP. PCP may require member to see an orthopedist or physical therapist prior to or instead of chiropractic care. Limited to $2,000 per benefit year for a specific problem. Excludes: spinal manipulations.
Cardiac Rehabilitation		Covers: Cardiac rehabilitative programs up to 90 consecutive days per occurrence per contract year; optical therapy for conditions expected to show significant improvement, as determined by Doctors Health Plan. Limits: Limited to 20 visits per illness per injury per contract year. Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available.
Other Therapy Services		Excludes: Pain management therapy (except as medically necessary).
Skilled Nursing Facility		Covers: Skilled nursing facility fully covered when admission to a participating facility is requested by a participating provider. Limits: Doctors’ case management program will authorize benefits in cases where it is clinically appropriate and where significant improvement can be expected. Requires precertification or prior authorization from Doctors and must be provided by participating provider or facility unless there is no participating provider available.
Home-Based Services
Home Health		Covers: Skilled nursing services. Limits: Nursing services are covered in full for up to 60 days per contract year. Doctors’ case management program will authorize benefits in cases where it is clinically appropriate and where significant improvement can be expected. Requires precertification or prior authorization from Doctors. Must be provided by participating provider or facility unless there is no participating provider available. Excludes: Meals, housekeeping and personal convenience or comfort items.
Private Duty Nursing		Excluded.
Hospice		Covers: Hospice if coordinated through Doctors Health Plan. Excludes: Meals, housekeeping and personal convenience or comfort items.
Transplants and Dialysis
Transplants		Covers: Organ or bone marrow transplants including liver, heart, corneal, bone marrow, lung, heart-lung, pancreas and kidney that meet the coverage criteria (see definition section for description of coverage criteria). Limits: Requires precertification. Services must be provided by a facility approved by Doctors for transplant. Not all participating facilities are approved transplant centers.
Dialysis		Covered.
Other Services
Dental		Covers: Dental service when medically necessary or as a result of an accidental injury. Emergency dental service for restoration due to trauma or accidental injuries to sound and natural teeth. Dental service provided after first office visit for consultation with specialist. Oral tumors and oral cysts with precertification follow-up care covered only if coordinated by a member’s PCP. Temporo-mandibular Joint Disfunction (TMJ) covered (including splints and intraoral appliances) when it results from congenital deformity, disease or accident. Surgical services for TMJ and Craniomandibular Pain Syndrome (CPS) are covered, but only if medically necessary and evidence of joint abnormality due to disease or injury from x-rays. Limits: Injuries that occur during the act of chewing or biting are not covered. Cost Sharing: Copayment will apply based on place of service. Excludes: Dental care and x-rays, including shortening of the mandible or maxillae for cosmetic purposes, correction of malocclusion and any dental treatment involved in TMJ syndrome or CPS.
Vision		Covers: Routine vision screening by PCP; eyeglasses, contact lenses and their fitting covered when used to treat cataracts. Also covers optical therapy. Cost Sharing: Copayments may apply. Excludes: Routine vision care, eyeglasses, contact lenses, (or the fitting of any of these) unless covered by a vision supplemental policy; refractic surgeries or procedures that lessen or eliminate the need for glasses or contact lenses.
Hearing		Covers: Routine hearing exam by PCP. Cost Sharing: Copayments may apply. Excludes: Hearing aids (including their purchase or fitting), unless covered by a rider.
Foot Care		Excludes: Foot care for routine nail cutting, corns, calluses, flat feet, fallen arches, weak feet or chronic foot strain.
Weight Loss		Covers: Appetite suppressants for a pathological condition such as Narcolepsy or Attention Deficit Disorder. Other services may be covered if medically necessary. Excludes: Appetite suppressants for other conditions, liposuction or any surgical procedure designed to remove excess fatty tissue unless medically necessary.
Smoking Cessation		Excludes: Any service or supply to eliminate or reduce nicotine addiction, including: nicotine withdrawal programs, patches and gum.
Growth Hormones		Excludes: Bone growth stimulators.
Alternative Therapies		Covers: Biofeedback treatment for medical conditions. Limits: Biofeedback covered up to 20 visits per contract year. Must be approved in advance by Doctors and must be provided by a participating provider or facility unless no participating provider is available. Excludes: Acupuncture; massage therapy; pain management therapy (except as medically necessary).
Reconstructive/Cosmetic Surgery		Covers: Reconstructive surgery to restore normal physiologic functioning due to disease, trauma or congenital anomaly. Includes surgery for minor children for conditions which, for medical reasons, cannot be done at birth. Also covers reconstructive breast surgery resulting from a mastectomy. Limits: Treatment of congenital defects in children is covered through age 18. Excludes: Surgery for cosmetic purposes or breast reduction surgery.
Non-Emergency Transportation		Covers: Reasonable travel and lodging costs for member (and, if the member is a minor, one parent or guardian) when Doctors refers the member to a medical facility outside the service area. This is only when comparable services are not available through a participating provider in the service area. Must be approved in advance.
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 commonly excluded services.
Definitions
Medically necessary		Meets statutory definition.
Experimental or Investigational		A drug, treatment, device or procedure that meets any of the following conditions: Cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of use or proposed use. Is the subject of a current investigation, new drug or new device application on file with the FDA; Is being provided as part of a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial. Is being tested to determine its’ safety, toxicity, maximum tolerated dose, or efficacy. Is being provided subject to the approval and supervision of an Institutional Review Board (IRB). The predominant opinion among experts as published in authoritative medical and scientific literature is that further research is necessary in order to define safety, toxicity, maximum tolerated dose, or effectiveness. There is a lack of any published authoritative medical and scientific literature addressing the efficacy of the treatment, drug, device or procedure. Is otherwise reasonably determined by Doctors’ to be experimental and investigational in nature. 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		Uses statutory definition of emergency.
Urgent Care		Services provided for a condition that occurs suddenly and unexpectedly requiring prompt diagnosis or treatment. In the absence of immediate care the individual could reasonably be expected to suffer an extended illness, prolonged impairment, or require a more hazardous treatment. Examples of conditions that may need urgent care include minor wounds requiring stitches, possible urinary tract infections, ear aces and muscle sprains.
Primary Cary Providers, referrals and Pre-authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider		Primary care providers are physicians in the specialties of internal medicine, family practice, pediatrics and general practice. Women may also select an OB/GYN as a secondary PCP (to provide routine obstetric and gynecological care).
What Happens if Member Fails to Choose a PCP?		If the member does not choose a PCP during enrollment, then he or she will be assigned to the first PCP the member sees.
Process to Change PCP		A member may change his/her designated PCP by filling out an enrollment application/ change form. This is done by calling Doctors’ member services department. A new identification card will be issued. Doctors’ reserves the right to determine how often a member may change his/ her PCP. A minimum opportunity of once per month is guaranteed.
Referrals to Specialists		Referrals to participating providers: Covered when referred by PCP and/or prior authorization by Doctors. Referrals to non-participating providers: Covered only when written prior authorization is given by Doctors’, in the case of an emergency, or when urgent care is needed. Referrals are not needed for female health services of an OB/GYN.
Can Specialists Serve as PCP?		No.
Non-Emergency Hospital preauthorization Requirements		Inpatient hospital services at a participating facility require precertification by Doctors’ Health Plan. Outpatient health services require prior authorization.
Appeal and Grievance Procedures
Informal Reconsideration		Members and/or their representatives are encouraged to contact Doctors Health Plan to try to resolve their concerns informally. In cases where informal resolution may not be possible, members are encouraged to use the appropriate formal review process. Note: No time limitations are specified 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 Doctors within 60 days their claims decision. Members will receive a response from Doctors within 30 days of Doctors receipt of the review request.
First Level Expedited Appeals		Follows statutory definition. Note: Responses to expedited appeals will be received within 96 hours of the receipt of all necessary information.
First Level Grievance Hearings		Follows statutory definition. Note: Members or their representatives must make grievance requests within 60 days of the incident. Members will be notified of the results within 30 days of Doctors receipt of the review request.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)		Follows statutory definition. Note: Requests for second-level grievance hearings must be made within 30 days of the first level appeal or grievance decision. The second-level review meeting will be held within 45 days of the PCP receives 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 received within 96 hours 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 N.C. Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes		Limitations of Informal and Formal appeal and grievance Process: The appeal and grievance process does not apply to denials rendered solely on the basis that Doctors Health Plan does not provide coverage for the health care service performed or being requested, as outlined in the Evidence of Coverage. The appeal and grievance process also will not apply to disputes regarding the dollar amount by which benefits are limited or the number of visits covered, if those limitations are clearly stated in the Evidence of Coverage or supplemental coverage. In addition, the right to appeal issues may be waived if a member fails to request an appeal within the time frames listed in the appeals process.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)		33,917
Member Months in 1999 (Financial Report, #11)		397,493
Average 1999 Monthly Enrollment (Member Months/12)		33,124
Percentage Change in Average Monthly Enrollment between 1998-1999		14.47%
Five-year Average Enrollment Trends		1999: 33,124 1998: 38,727 1997: 22,910 1996: 6,690 1995: 1,004
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)		16%
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)		16%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)		12%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)		0%
Utilization Review Information
Number of. Reviews Requested, 1999
Review Rate per 1,000 Members, 1999
Percentage of Noncertifications, 1999
Noncertification Rate per 1,000 Members, 1999
Appeal Rate per 1,000 Noncertifications, 1999
Percentage of Appeals Decided for the Members, 1999
Financial Data
Total 1999 Revenues (Financial Report, #6)		$58,053,257
Average Premium per member per month (1998) (Financial Report, #5 / #11)		$145.17
Five-Year Premium per member per month Trends		1999: $145.17 1998: $122.83 1997: $117.40 1996: $119.84 1995: $116.30
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1999		$147.01
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1998		101.3%
Five-Year Medical Loss Ratio Trends		1999: 101.3% 1998: 112.4% 1997: 114.1% 1996: 91.1% 1995: 85.4%
Operating profit margin (Financial Report, #9 / #6)		(16.8%)
Five-year Operating Profit Margin Trends		1999: (16.8%) 1998: (22.8%) 1997: (48.0%) 1996: (48.1%) 1995: (167.4%)
Sources of Information
Source of Information		Doctors Health Plan, Inc., DHP/MEM. CERT (7/98) ; 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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