GENERATIONS FAMILY 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	Generations Family Health Plan, Inc. received its HMO license from the NC Department of Insurance April 2, 1997. It commenced business on November 1, 1997. Generations is a for-profit corporation, owned by Wake Medical Center and the University of North Carolina Health Care System.
Type of HMO	Generations operates as an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Type of Products	Generation’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. Generations also offers a point-of-service option, called "Legacy Plus."
Accreditation	Generations 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 Generations Family Health Plan is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees	Generations offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group"), Medicaid, or Medicare beneficiaries, although some Medicare beneficiaries may have supplemental HMO coverage through their employer.
Counties in which HMO has an Active Presence	Generations has at least 25 commercial (group) HMO members at the end of 1999 in the following North Carolina counties: Alamance, Chatham, Durham, Franklin, Granville, Harnett, Johnston, Lee, Nash, Orange, Wake and Wilson.
Customer Service Number	1-888-256-5563
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services	Covers: Room and board for a semi-private room (or private room when medically necessary). General nursing care. Meals and special diets. Operating room and related facilities, including anesthesiologist services. Intensive and cardiac care units and services. Drugs, medications and biologicals Anesthesia and oxygen. Administration of whole blood and blood plasma. Limits: Prior authorization must be obtained by the PCP or Participating Specialist for all inpatient services. Cost Sharing: Copayments, coinsurance and/or deductibles may apply.
Outpatient services	Covers: Radiological and nuclear medicine, such as x-rays and MRIs. EKGs and EEGs. Also covers laboratory procedures, chemotherapy, radiation therapy, dialysis, anesthesiologist services and surgical procedures with prior authorization. Limits: Prior authorization must be obtained by the PCP or Participating Specialist for all outpatient surgery and facility procedures.
Emergency care	Covers: Emergency services within medical service area: Call 911 or go immediately to nearest hospital emergency room. If you have any medically--related questions, you can call a Generations nurse triage/advice line at any time Emergency services outside service area: Follow same procedure as you would within the Service Area. Notification requirements: None. Members are advised to notify their PCP and/or Generations as soon as possible after receiving services. Cost Sharing: Copayments apply. The Emergency Room copayment will be waived if the emergency results in a hospitalization. Excludes: Non-emergency use of the emergency room. If Generations determines that your condition does not meet the definition of an emergency, you will be responsible for all charges.
Urgent Care	Covers: Urgent care within service area. Limits: Members should contact their PCP, who will direct them to the most appropriate location for treatment, either his/her office or one of Generations’ Participating urgent care centers.
Ambulance	Covers: Ambulance services when medically necessary. Services covered from the site of injury or onset of symptoms to the nearest hospital, in or outside the service area. Limits: Transport between facilities must have Prior authorization. Excludes: Transportation by a non-participating provider or for care that is determined not to be a true emergency.
Care for Students Outside of Service Area	Covers: Emergency or urgent care services only.
Non-Urgent Care Outside of Service Area	Excluded.
Professional Services
Professional Services (general)	Covers: Office visits to PCP for diagnosis and treatment of illness or injury. Specialist care and consultations. Physician services during inpatient admissions. PCP home visits. Injectable drugs obtained from a participating provider or home infusion agency (except Imitrex and insulin). No cost sharing.
OB/GYN	Covers: Services of OB/GYN for routine obstetric and gynecological care for services related to the female reproductive system and breasts. Referral not required. Limits: Covers one complete well-woman exam per benefit period, and exams for diagnosis and treatment of illness or injury. No cost sharing.
Diagnostic Procedures	Covers: Laboratory and diagnostic tests; radiology and nuclear medicine. Limits: Prior authorization required for certain MRIs.
Therapeutic Treatment Services	Covers: radiation, chemo-therapy, respiratory therapy
Allergy Testing	Covers: Allergy testing and immunotherapy. Excludes: Treatment for food allergies.
Preventive Services
Annual Physicals (well-baby, well-child)	Covers: Well-child care; one complete physical examination per benefit period; hearing screening and audiometric testing by PCP; routine vision screenings by PCP for children up to 18. Excludes: School physicals, premarital exams and physical exams for employment, sports or insurance. No cost sharing.
Immunizations	Covers: Pediatric and adult immunizations. Excludes: Immunizations needed for foreign travel. No cost sharing.
Preventive Clinical Services	Covers: Pap smears, mammograms and PSA tests (as required by state law). No cost sharing.
Other Health Promotion/Disease Prevention Activities	Covers: Health education classes and services when deemed medically necessary and with prior approval by Generations.
Diabetic Treatment	Covers: Outpatient self-management training and educational services when approved in advance by Generations. Also covers equipment, supplies, medications and laboratory procedures related to the management of diabetes. Limits: Insulin pumps require prior authorization. Excludes: Over the counter medication and supplies.
Conception Services
Prenatal Care and Obstetrical Services.	Covers: Professional maternity services, including pre-natal care, physician services associated with delivery , and post-natal follow-up care. Cost-Sharing: Covered 100% after a one time office visit copay made at first pre-natal physician office visit.
Family Planning	Covers: Counseling and education about birth control. Counseling and diagnostic services for genetic problems and birth defects. Tubal ligation and vasectomy procedures. Birth Control pills, IUDs, Norplant and Depo Provera.
Abortion	Covers: Abortions, therapeutic or elective.
Infertility Services	Covers: Diagnostic services to establish the cause of infertility. Excludes: Reversal or surgical sterilization, drug therapy, in-vitro fertilization, embryo transplants, the GIFT program, artificial insemination, tuboplasty and other treatments to induce pregnancy.
Mental Health and Substance Abuse Services
Mental Health Inpatient	Covers: Mental health inpatient admissions when deemed medically necessary and approved in advance by a Generations’ Mental Health network provider, Magellan. Limits: Benefits limited to maximum of 30 days inpatient facility services per contract year. Care must be authorized by Magellan.
Mental Health Outpatient	Covers: Medically necessary mental health outpatient services if approved in advance by Generations’ Mental Health network provider, Magellan. Limits: Benefits limited to maximum of 20 visits per contract year. Care must be authorized by Magellan. Excludes: Services for learning or behavioral disabilities, mental retardation or autism.
Substance Abuse Inpatient	Covers: Inpatient detoxification for drug or alcohol abuse or addiction when deemed medically necessary and approved in advance by Generations’ Mental Health network provider, Magellan. Limits: Benefits, combined inpatient and outpatient, maximum of $8,000 per contract year and $16,000 lifetime. All care must be authorized by Magellan.
Substance Abuse Outpatient	Covers: Outpatient care including diagnosis, medical treatment and referral services for alcohol or drug abuse or addiction. Also covers ancillary and detoxification services. Limits: Benefits, combined inpatient and outpatient, maximum of $8,000 per contract year and $16,000 lifetime. All care must be authorized by Magellan.
Prescription Drugs and Medical Supplies
Prescription drugs	Covers: Prescription drugs if purchased from a participating pharmacy and prescribed by a participating or non-participating provider. Covers injectable drugs from participating provider or home infusion agency. Drugs from non-participating pharmacies will be covered in the case of an emergency. Limits: The benefits apply to generic drugs only, unless no generic equivalent exists or the prescribing physician indicates there cannot be a generic substitution for a specific brand name product. Cost Sharing: Copayments for generic and brand name drugs are different. The patient will be required to pay the regular copayment and the difference in costs between the brand name drug and its generic if the patient requests a brand name drug (when the physician does not indicate that there cannot be a generic substitution). Excludes: Medications for smoking cessation, anorexia, or cosmetic purposes. Drugs that are investigational, do not have FDA approval, are not generally prescribed in the course of acceptable medical practice or have not been shown consistently effective for the diagnosis or treatment of the condition. Administration charges. Drugs that do not require a prescription. Drugs prescribed for non-medical conditions. Immunization agents. Medications for treatment of infertility or to induce pregnancy Nutrition administered intravenously for individuals unable to tolerate tube feeding ("total parenteral nutrition"). Injectable drugs.
Blood	Covers: Costs of administering blood. Excludes: Blood.
Medical Supplies	Covers: Medical supplies such as colostomy bags, catheters, oxygen, needles, and syringes when ordered by a physician based on medical necessity. Excludes: Deluxe versions of durable medical equipment or prosthetic devices unless medically necessary. Also excludes over the counter medications and supplies commonly procured for home treatment of simple ailments and injuries.
Insulin and Diabetic Supplies	Covered.
Durable Medical Equipment, Prosthetics, and Orthotics
Prosthetic Devices	Covers: Initial and medically necessary replacement prosthesis when on Medicare’s list of approved prosthetic appliances and approved by Generations’ medical director. Also covers surgically implanted prosthetic devices. Exclusions: Deluxe versions of durable medical equipment or prosthetic devices unless medically necessary.
Orthotic Devices	Excluded.
Durable Medical Equipment (DME)	Covers: Rental or purchase of durable medical equipment, whichever is less expensive. Limits: DME must be requested by the PCP and authorized in advance by Generations. Customized DME covered with prior authorization from Generations. Excludes: Deluxe versions of durable medical equipment or prosthetic devices will not be covered unless medically necessary. Also excludes non-medically necessary appliances.
Rehabilitative and Habilitative Services
Physical therapy	Covers: Short-term outpatient physical therapy when determined to be medically necessary by Generations’ Medical Management Department. Limits: Therapy is covered only to restore physical ability to the pre-injury or pre-illness level or function (no therapy beyond this level is covered). Benefits limited to maximum of 30 visits per incident per contract year. Exclusions: Therapy to correct impairment resulting from a functional disorder, such as learning delay, autism or stuttering.
Occupational therapy	Covers: Short-term occupational therapy to restore self-care and the ability to function in the activities of daily living (such as dressing, feeding, bathing, etc.). Limits: Only covers services determined to be medically necessary by Generations’ Medical Management Department. Benefits limited to maximum of 30 visits per incident per contract year. Exclusions: Therapy to correct impairment resulting from a functional disorder. Excludes vocational rehabilitative services.
Speech Therapy	Covers: Short-term speech therapy on an outpatient basis to correct an impairment of organic origin due to an injury or illness, or following surgery to correct a congenital defect (Surgery must have been done while a Generations’ member). Limits: Speech therapy only provided if determined to be medically necessary by Generations’ Medical Management Department. Therapy is covered only to restore speech ability to the pre-injury or pre-illness level or function. (No therapy beyond this level is covered). Benefits limited to maximum of 30 visits per incident per contract year. Exclusions: Speech therapy to correct impairment resulting from a functional nervous disorder, for delayed or abnormal speech pathology.
Pulmonary Therapy	Covered.
Chiropractic	Covered. Limits: Must have PCP referral.
Cardiac Rehabilitation	Covered.
Other Therapy Services	Excludes: Sex therapy and recreational therapy.
Skilled Nursing Facility	Covers: Skilled nursing facilities when prescribed, directed or authorized by PCP and approved in advance by Generations’ Medical Management Department. Covers SNF stays that supplement or substitute for inpatient hospitalization. Limits: Benefits limited to maximum of 100 days per contract year, and 200 days lifetime. Excludes: Respite, custodial and convalescent care if skilled nursing care is not required.
Home-Based Services
Home Health	Covers: Home health if medically necessary and expected to result in significant improvement of condition. Can include home infusion therapy and services of a home health aide if medically necessary. Benefits limited to 100 visits per contract year. Excludes: Meals, housekeeping, personal convenience or comfort items.
Private Duty Nursing	Excluded, unless ordered by PCP for medically necessary reasons.
Hospice	Covers: Outpatient and inpatient care of a terminally ill member. Limits: Requires prior approval. Excludes: Homemaker, volunteer and spiritual counseling services, curative treatment or services, food or home-delivered meals, custodial care, rest care or care for someone’s convenience.
Transplants and Dialysis
Transplants	Covers: Heart, lung, heart-lung, kidney, liver, pancreas, cornea, bone marrow and other non-experimental transplants deemed medically necessary. Also covers donor’s costs if the recipient is a member (the donor’s costs are charged to the recipient’s benefits). Travel and lodging for plan-authorized organ and bone marrow transplants are also covered. Limits: Transplants must be authorized by PCP and approved in writing in advance by Generations Medical Management Department. Services must be provided in an approved institution. Excludes: Donor-related costs when the donor is a member but the recipient is not.
Dialysis	Covered.
Other Services
Dental	Covers: Services for tumors or cysts of the mouth, fractures of the jaw or for correction of congenital malformation. Oral surgery is covered when an injury or accident prevents normal functioning. Treatment is required within 60 days of the accidental injury or when necessary due to injury, disease or congenital defect. Covers diagnostic and therapeutic procedures for bones or joints of the jaw, face or head if condition prevents normal functioning and resulted from injury, illness or congenital defects. Excludes: All other dental services, including cleaning, treatment, filling, removal or replacement of teeth or tissue directly supporting the teeth, or apicoectomy (dental root resection). Orthodontics appliances and braces. Root canal treatment. Impacted wisdom teeth. Soft tissue impaction. Myofacial pain. Dysfunction examination, evaluation and treatment, Alveolectomy. Treatment of periodontal disease. X-rays.
Vision	Covers: Routine vision screening by child’s PCP for children up to age 18. Screening includes a case history, visual acuity test, screening tests for disease or abnormalities, including glaucoma and cataracts. Also covers optical services and surgery when medically necessary, including the placement of intraocular lenses and the first pair of eyeglass lenses or contacts following cataract surgery. Generations provides discounts on eyeware and non-disposable contacts. Limits: Routine vision examinations limited to office visit with child’s PCP. Screenings may not be performed by an optometrist or ophthalmologist unless beneficiary purchases routine vision screening rider. Excludes: Eyeglasses, contact lenses or their fitting (unless first pair following cataract surgery); vision therapy; services required by employer; surgery to correct refraction errors.
Hearing	Covers: Hearing screening and audiometric testing by PCP. Excludes: Hearing aids.
Foot Care	Covers: Routine foot care for diabetic or other metabolic or peripheral vascular disease. Excludes: Routine care.
Weight Loss	Covers: Weight loss only in the case of aggravating medical conditions as determined by physician and with prior approval of Generations. Excludes: Weight loss services in the absence of aggravating medical conditions.
Smoking Cessation	Excludes: Treatment for nicotine dependency or smoking cessation is not covered.
Growth Hormones	Covers: Growth hormone when medically necessary for congenital defects.
Alternative Therapies	Covers: Acupuncture performed by a participating provider and used as a form of anesthesia in connection with a covered surgical procedure. Excludes: Acupuncture for other purposes.
Reconstructive/Cosmetic Surgery	Covers: Reconstructive surgery needed to correct congenital disease or anomaly, or to correct a functional impairment. Covers post-mastectomy breast surgery.
Non-Emergency Transportation	Covers: Travel and lodging for plan-authorized organ and bone marrow transplants for patient and, if patient is a minor child, for one parent.
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	Procedures or services that, in the judgment of Generations: Are in a testing stage or in field trials on animals or humans. Do not have required final federal regulatory approval for commercial distribution for the specific purpose being assessed. Are not in accordance with generally accepted standards of medical practice. Have not yet been shown to be consistently effective for the diagnosis or treatment of the member’s condition.
Emergency	Uses statutory definition of emergency.
Urgent Care	Health problems that require immediate attention but are not life- or limb-threatening emergencies. Immediate attention means that care is required within 24 hours of the injury or illness in order to prevent deterioration of the condition to a medical emergency.
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 Family Practice, Pediatrics and Internal Medicine.
What Happens if Member Fails to Choose a PCP?	Until PCP is selected, benefits limited to coverage of emergency. If a PCP is not selected, Generations may select one
Process to Change PCP	A member may change his/her designated PCP by calling the member service department to let them know of the PCP change. There are no restrictions on the number PCP changes allowed.
Referrals to Specialists	Referrals to a Consulting Specialist: The member’s PCP must arrange referrals to specialists, hospitals or other facilities for surgeries or care. Referrals to a nonparticipating provider: Referrals to non-participating providers are allowed in the event that participating providers are not available to treat you without unreasonable delay. Prior authorization from Generations is required for all referrals to non-participating providers. When referred to non-participating providers, members may be responsible for filling out and submitting claims. Referrals are not needed for female health services of an OB/GYN.
Can Specialists Serve as PCP?	No.
Non-Emergency Hospital Preauthorization Requirements	PCP or participating specialist to whom member was referred must obtain prior authorization from Generations’ Medical Management Program. Generations will assign an initial length-of-stay based on information provided by the physician.
Appeal and Grievance Procedures
Informal Reconsideration	Generations will try to informally resolve members’ complaints. Call the Member Services Department to begin the informal review process. The informal review of a decision to deny services will be conducted between the member’s provider and a doctor picked by Generations. 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 Generations following their informal reconsideration, UM or claims decision. No time limitations are specified in the Evidence of Coverage. Members will receive a response from Generations within 30 days of Generations’ receipt of the review request.
First Level Expedited Appeals	Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
First Level Grievance Hearings	Follows statutory definition. Note: Members or their representatives must request a grievance review. No time limitations are specified in the Evidence of Coverage. Members will be notified of the decision within 30 days of Generations’ receipt of the review request.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)	Follows statutory definition. Note: Members or their representatives must request a second-level grievance hearing. No time limitations are specified in the Evidence of Coverage. The second-level review meeting will be held within 45 days of Generations’ 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 received within 4 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 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 Generations does not provide coverage for the health care service performed or being requested, as outlined in the Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)	12,782
Member Months in 1999 (Financial Report, #11)	109,561
Average 1999 Monthly Enrollment (Member Months/12)	9,130
Percentage Change in Average Monthly Enrollment between 1998-1999	244.51% Note: Generations newly operational as of 1997
Five-year Enrollment Trends	1999: 12,728 1998: 2,650 Not available other years
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)	17%
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)	19%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)	11%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)	0%
Utilization Review Information
Number of. Reviews Requested, 1999	2,378
Review Rate Per 1,000 Members, 1999	1,003
Percentage of Noncertifications, 1999	3.32%
Noncertification Rates per 1000 Members	33.32
Appeal Rate per 1,000 Noncertifications, 1999	N/A
Percentage of Appeals Decided for the Members, 1999	N/A
Financial Data
Total 1999 revenues (Financial Report, #6)	$15,492,183
Average Premium per member per month (1999) (Financial Report, #5 / #11)	$139.30
Five-Year Premium per member per month Trends	1999: $139.30 1998: $128.79 1997: N/A 1996: N/A 1995: N/A
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1999	$120.25
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1999	86.3%
Five-Year Medical Loss Ratio Trends	1999: 86.3% 1998: 92.1% 1997: N/A 1996: N/A 1995: N/A
Operating Profit Margin (Financial Report, #9 / #6), 1999	(17.6%)
Five year operating profit margin trends	1999: (17.6%) 1998: (73.6%) 1997: N/A 1996: N/A 1995: N/A 1994: N/A
Sources of Information
Source of Information	Generations Family Health Plan, Inc., Evidence of Coverage, Legacy LegF 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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