General Information

The side-by-side comparison of HMOs begins with basic informationbasic information about the health plans

• Background Information: This section includes information on the date that the HMO was licensed to operate by the N.C. Department of Insurance. This gives you an indication of how long the HMO has operated in the state.
  
  The background information includes information on the corporate status of the HMO, e.g., whether the HMO is a for-profit or not-for-profit company. For-profit companies distribute profits to shareholders, whereas not-for-profit companies must put their earnings back into the company. Most of the HMOs in North Carolina are for-profit companies. In June of 1998, 73 percent of the HMO enrollment in North Carolina was in for-profit companies.
  
  The name of the parent company is also listed in this section. This gives an indication of whether the control of the company resides in North Carolina or with a parent organization outside of the state.
  
  
• Type of HMO: This describes whether the HMO has its own set of doctors and clinics (called a staff/group model), or whether the HMO contracts with a network of physicians practicing in the community (called an IPA/network model). Most of the HMOs that operate a staff/group model system also contract with some community physicians. These models are called "mixed group/IPA model" HMOs. HMOs that operate IPA/network models typically have a larger network of providers. However, HMOs that have its own set of doctors and clinics may be able to more closely monitor the care provided to its members.
  
  
• Types of Products: Currently, all of the HMOs in North Carolina offer a "gatekeeper" type of product. In a gatekeeper system, you must choose a primary care provider who is responsible for managing all your care. For example, the primary care provider would be required to refer you to a specialist, or authorize a non-emergency admission to the hospital.
  
  Several HMOs also operate an "open-access" type of product. Open-access plans do not use "gatekeepers." In an open-access HMO, you are allowed to see any of the physicians listed in the provider network, both primary care providers and specialists. You do not need to first get a referral from a primary care provider. However, you may need to get prior authorization from the HMO before non-emergency admissions to the hospital, or for certain other tests or procedures.
  
  This section also tells whether the HMO offers a point-of-service (POS) plan. A point-of-service plan gives the patient the opportunity to see providers outside of the network. However, patients who use the HMO network of providers pay less than patients who see providers outside the network. The HMO may still require the use of a gatekeeper to authorize in-network services. If the HMO offers a point-of-service plan, the name of the POS plan is listed.
  
  
• Accreditation: This section identifies the HMOs with NCQA accreditation. Seven of the HMOs in North Carolina obtained accreditation through 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. Once a review is completed, a health plan will be given an accreditation decision. 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. Beginning October 1999, health plans that exceed NCQA’s standards and are demonstrate the highest rankings can also obtain an Excellent status. 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.

Product Offerings

This section provides information about the types of products that the HMOs offer.

• Enrollees: This section describes whether the HMO markets to both large and small employers, and whether the HMO enrolls Medicaid or Medicare recipients. Small employers are defined as employer groups with fewer than 50 employees. An HMO that is does not offer HMO coverage to individual Medicare recipients may still cover certain Medicare recipients through employer retirement plans.
  
  
• Counties in Which HMO Has An Active Presence: This section lists the counties in which the HMO had an active presence at the end of 1998. Active presence is defined as having at least 25 HMO commercial group members.
  
  
• Customer Service Number: This section includes the HMO’s customer service number. You can call this number if you have questions about the HMO or its operations.
  
  
• However, this section is limited to those plans that offer Medicare HMO risk plans to the general Medicare population.

Covered and Excluded Services

This section describes the HMOs’ covered services, limitations and exclusions. The description of an HMO’s benefit coverage will usually have three sections:

1. "Covers" describes the services covered under the plan. Even if a service is listed as "covered," it may not be covered fully, and will generally only be covered if the service is medically necessary.
2. "Limits" describes whether the plan requires prior approval or day, dollar, or visit limits.
3. "Cost Sharing" describes whether the plan requires cost sharing.
4. "Excludes" describes services that are excluded under the plan.

Each HMO offers many different arrangements. While most of the services offered by a particular HMO will be the same across its different plans, some services vary. For example, HMOs may offer additional coverage through supplemental policies, called "riders." Vision and dental coverage are common examples of services that are only offered through riders. In addition, some HMOs offer mental health, substance abuse and prescription drug coverage through riders.

The description of an HMO’s covered and excluded services shown in the chart is based on the most commonly purchased HMO plan. The plan that you are offered may or may not include the same coverage or limitations as listed in this comparison. Thus, the information contained in the comparison is only a starting point to use in comparing HMOs. It is important for you to check your Evidence of Coverage to see what services are provided.

HMOs also vary copayments and other cost sharing in their different plans. We did not include specific cost sharing requirements in this comparison because of the great differences across plans. However, we tried to indicate the services for which there would likely be some type of cost sharing, such as copayments, coinsurance or deductibles.

Definitions

This section includes words that may have a specific definition for each HMO. These words include: medically necessary, coverage criteria, experimental or investigational, emergency and urgent care.

Primary Care Providers, Referrals and Preauthorization Requirements

• Types of Providers who Can Serve as primary care providers. Some HMOs limit the type of provider who can serve as the primary care provider. Typically HMOs require members to pick a doctor with a specialty in family medicine, internal medicine or pediatrics to serve as the member’s primary care provider or "gatekeeper." Some plans also allow obstetrician-gynecologists to serve as a primary care provider.
  
  
• What happens if Member Fails to Choose a PCP. This section describes any procedures or limitations if you fail to pick a PCP. Some plans will choose a PCP for you if you fail to choose your own primary care provider. Other plans may exclude coverage for all but emergency services if you fail to choose a primary care provider.
  
  
• Process to Change PCP. This section describes the steps to follow if you want to change your primary care provider. Some plans limit the number of times that you can change primary care providers. Others have no specified limits.
  
  
• Referrals to Specialists. The HMOs that operate "gatekeeper" systems typically require that the primary care provider authorize all referrals to specialists. This section describes the referral requirements.
  
  
• Can a Specialist Serve as a PCP? None of the Evidences of Coverage examined state that the HMOs allow specialists to serve as a primary care provider. While the Evidences of Coverage were generally silent on this point, some HMOs allow certain individuals with specific medical conditions to use their specialist as their primary care provider. It is worth contacting your HMO if you have special health care needs and want to use your specialist as the gatekeeper who is responsible for arranging and managing all of your covered services.
  
  
• Non-Emergency Hospital preauthorization Requirements: All of the HMOs require you to obtain prior authorization from your primary care provider and/or the HMO before seeking non-emergency care from the hospital. United HealthCare of North Carolina requires this only for inpatient services.

Appeal and Grievance Procedures

This section describes the appeal and grievance procedures for each health plan. Health plans are required by state law to offer certain appeal and grievance procedures. These procedures are listed below. Health plans do have the option to impose time limitations on filing the appeals or grievances. These specific plan limitations, as well as any other plan specific information, are listed in the appropriate section.

Plan members have two separate appeal routes. One takes place when the member contests a decision to deny or limit health care services "non-certification decision". This is called an appeal. The other appeal route occurs when a member is unhappy with other aspects of the plan’s operations. A complaint about other operations of the plan is called a grievance.

Members have the right to two levels of review, for both appeals and grievances. The first level of review has a different name and a slightly different process depending on whether it is a first-level appeal or first-level grievance review. However, the second-level review is the same regardless of whether the dispute is a denial of services or another problem with the plan’s operation. This is referred to as a second-level grievance hearing.

Members who contest non-certification decisions (denials of services or procedures) have a right to ask for expedited review if the normal time limits could hurt the person’s health. Otherwise, the normal time limits apply. There is not an expedited process for first-level grievance decisions, because first-level grievance hearings do not deal with non-certification decisions (these are handled at the first level appeals).

• Informal Reconsideration. This section describes any informal process that the HMO has to resolve disputes quickly. The informal process is voluntary.
  
  
• First Level Appeals: Members can file an appeal on their own behalf. In addition, a physician or other person acting on the member’s behalf can file an appeal. All plans must offer at least two levels of appeals. A physician who was not involved in the original decision must hear the first appeal. Normally the physician has 30 days to decide the appeal.

• First Level grievance Hearings: The member, his representative or the provider may submit a first-level grievance. The HMO must provide the member with information on how to submit written materials, within three business days after receiving notice of the grievance. The person reviewing the grievance cannot be the same person who initially handled the grievance. If the issue is a clinical one, at least one of the reviewers must be a medical physician with appropriate expertise. The HMO must make a grievance decision within 30 days after receiving the complaint. The notice of the decision must include the same information as provided in first-level appeal decisions.
  
  
• Second Level grievance Hearings: HMOs must also have second-level grievance reviews for members who are dissatisfied with the decision of the noncertification appeal or first level grievance review. The HMO must notify the member of the name and telephone number of the grievance coordinator, as well as information about the second-level grievance process within 10 days of receiving a request for a second-level grievance. Members have more extensive due-process rights at the second-level grievance review. Specifically, a member can attend the second-level grievance-hearing, request and receive all information relevant to the case in order to prepare for the hearing. Members may present his or her case to the review panel, submit supporting materials before and at the review meeting, ask questions of any member of the review panel and bring another person to help in the review hearing. These could include a family member, employer representative or attorney. If the member chooses to bring an attorney, then an attorney may also represent the HMO. The HMO will convene a hearing panel to hear second-level grievances. The panel will usually be comprised of people who are not employees of the HMO or utilization review organization, who were not previously involved in the decision, and who do not have a financial interest in the outcome of the review. All of the people reviewing a second-level grievance involving a non-certification or clinical decision should be providers who have appropriate expertise in the health issue in dispute. The review panel has up to 45 days to hold the hearing, and up to 15 days thereafter to make a decision. This decision is a recommended decision to the HMO.

• Second Level Expedited Appeals: Members can request an expedited second-level review if their health could be harmed because of any time delays. Members may request an expedited second-level review even if the first-level appeal or grievance review was not expedited. If necessary, the HMO may conduct the hearing over the phone or through submission of written information.
  
  
• Other Avenues of Appeal: Members can obtain independent information and seek help from the Department of Insurance in settling the dispute. The Department of Insurance’s Consumer Services Division answers the public’s complaints or questions about insurance companies. Sometimes the Department will intervene and try to negotiate a solution with the HMO when it thinks that the consumer has a justified complaint. The Department of Insurance’s telephone number is: 1-800-662-7777 or 1-800-546-5664.
  
  
• Notes: This section includes any other plan specific information not included in the above sections.

Enrollment Data

• Enrollment. This gives the HMO’s annual enrollment numbers as of December 31, 1998 as reported to the N.C. Department of Insurance in the annual Financial Statement. Enrollment numbers reflect commercial, Medicare and Medicaid enrollees where applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Prudential, The Wellness Plan of North Carolina, Inc. and United Healthcare have Medicaid enrollees.
  
  
• Member Months. This lists the number of months of coverage for all of the HMO’s members in 1998. Someone who enrolls in a plan on January 1^st of a year and continues their enrollment in the plan for the entire year will account for 12 member months. A person who enrolls on December 1^st of a year will only have one member month in that year. The total number of member months describes how many members the HMO served each month over the entire year. Looking solely at the enrollment numbers at the end of the year could be misleading, as an HMO that enrolled all its members at the end of the year would have had to provide less services to an HMO that has the same annual enrollment numbers but enrolled most of its members in January. Enrollment numbers reflect commercial, Medicare and Medicaid enrollees where applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Prudential, The Wellness Plan of North Carolina, Inc. and United Healthcare have Medicaid enrollees.
  
  
• Average 1998 Monthly Enrollment. This is the average monthly number of enrollees for each of the HMOs. It is the total member months divided by 12. Since HMOs enroll members at different times in the month, the average monthly enrollment is a better reflection of the numbers of members that the HMO typically serves. Average monthly enrollment can be used to compare the enrollment among different HMOs. Enrollment numbers reflect commercial, Medicare and Medicaid enrollees where applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Prudential, The Wellness Plan of North Carolina, Inc. and United Healthcare have Medicaid enrollees.
  
  
• Percentage Change in Average Monthly Enrollment. This number shows whether the HMO added or lost members between 1997 and 1998. Enrollment numbers reflect commercial, Medicare and Medicaid enrollees where applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Prudential, The Wellness Plan of North Carolina, Inc. and United Healthcare have Medicaid enrollees.
  
  
• Five-Year Enrollment Trends. This data shows the change in annual average monthly enrollment over the last five years. Enrollment numbers reflect commercial, Medicare and Medicaid enrollees where applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Prudential, The Wellness Plan of North Carolina, Inc. and United Healthcare have Medicaid enrollees.
  
  
• Number of Groups that Disenrolled in a Calendar Year. Disenrollment numbers may give an indication of satisfaction with a health plan. If a large number of groups leave a health plan, this may indicate dissatisfaction or quality-of -care problems. However disenrollment numbers should be read with some caution. Groups may disenroll from health plans for a variety of reasons. For example, a health plan that raises its premiums may force an employer to choose a lower cost plan. An HMO may stop covering a particular part of the state, forcing some groups to purchase another plan. So while some groups may disenroll because of dissatisfaction with the plan, others may disenroll for reasons unrelated to quality or the care previously received.
  
  
• Number of Members who Disenrolled. In theory, disenrollment numbers may give an indication of satisfaction with a health plan. If a large number of members leave a health plan, it may indicate dissatisfaction or quality of care problems.
  
  Disenrollment numbers should be read with some caution. Individuals may disenroll from health plans for a variety of reasons. For example, a health plan may have raised its premiums forcing some enrollees to choose a lower cost plan. An HMO may stop covering a particular part of the state, forcing some enrollees to choose another plan. So while some members may disenroll because of dissatisfaction with the plan, others may disenroll for reasons unrelated to quality or the care previously received.
  
  
• Number of Providers who Resigned from the Plan. This lists the number of providers who have voluntarily chosen to stop participating in a plan. Disenrollment numbers may give an indication of satisfaction with a health plan. If a large number of providers leave a health plan, it may indicate dissatisfaction or quality of care problems. However provider resignation numbers should be read with some caution. Not all voluntary resignations are due to dissatisfaction with quality of care or HMO policies. For example, HMOs that contract with university faculty practices may appear to have a high rate of resignations. But that may be due to the number of doctors who finish their residencies and move away from the service area.
  
  
• Number of Providers who were Terminated. This number indicates the number of providers that the HMO asked to leave the plan. An HMO may terminate a provider from a plan for a number of reasons, including concern with the quality of care provider, failure to follow HMO internal procedures, inappropriate use of services or health care services, or because the HMO stops offering coverage in a particular community.
  

Utilization Review Information

• Number of Reviews. This lists the number of health services, procedures or tests that the HMO reviewed in 1998. Utilization review includes requests for prospective reviews (e.g., precertification or prior authorization requirements), concurrent review (e.g., hospital length of stay reviews) and retrospective reviews. HMOs are required to report data separately for inpatient, outpatient, specialty, pharmacy, mental health inpatient, mental health outpatient, some emergency services, and other reviews. The number of reviews should be read with some caution. The HMOs may not be reporting their data consistently. For example, Blue Cross Blue Shield appears to have an internal mechanism to report all (or most) of its claims for internal quality assurance purposes. Therefore, BCBSNC appears to have an abnormally large number of reviews (and review rate per 1,000 members). The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported across plans.
  
  
• Review rate per 1,000 members. This gives the average number of procedures that the HMOs reviewed per member in 1998. We calculated the average review rate per 1,000 members by taking the total number of reviews, dividing it by the average number of members reported to the NC Department of Insurance and multiplying this by 1000. For example, a review rate of 200 means that the HMO reviewed 200 procedures for every 1,000 members. The review rate can help identify HMOs with more stringent utilization review systems. The HMOs with the higher rates review health care services, tests and procedures more often than those with lower review rates. The utilization review rate only describes the frequency that health care procedures are subject to review. The review rate does not describe whether the reviews were approved or denied. The review rates per 1,000 members should be read with some caution. The HMOs may not be reporting their data consistently. For example, Blue Cross Blue Shield appears to have an internal mechanism to report all (or most) of its claims for internal quality assurance purposes. Therefore, BCBSNC appears to have an abnormally large number of reviews (and review rate per 1,000 members). The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported
  
  
• Number of Noncertifications: This number is the number of service denials in 1998. It is important to remember that HMOs deny services for many reasons. Some HMOs deny health care services because there are other services that can better meet the health care needs of the patient. Other HMOs deny services because they have stricter standards about what they consider appropriate health care services. Comparing denial rates across HMOs can help identify HMOs that are more likely to deny requested services. However, these rates will not show how the HMO will handle your particular medical needs. The noncertification numbers should be read with some caution. The HMOs may not be reporting their data consistently. For example, there are some indications that some HMOs did not include all the denials of emergency services in their non-certification numbers. This would make their number of noncertifications appear smaller than the HMOs that do report all emergency room service demands. The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported.
  
  
• Percentage of Non-Certifications. This is the percentage of all reviews that are denied by the health plan. It is important to look at both the utilization review rates (see above) and the denial rates (percentage of non-certification). An HMO that does not require prior authorization for most procedures may have a low review rate. However, it may have a higher denial rate as it limits the reviews to the services that are more likely to be denied. Another HMO may have a high review rate, but a lower denial rate. While review and non-certification rates can identify plans with more or less stringent utilization review systems, these rates will not show how the HMO will handle your particular medical needs. The percentages of non-certifications should be read with some caution. The HMOs may not be reporting their data consistently. For example, there are some indications that some HMOs did not include all the denials of emergency services in their non-certification numbers. The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported
  
  
• Non-Certification rates. This is the average number of service denials per 1,000 members in 1998. We calculated the average non-certification (denial) rate per 1,000 members by taking the total number of denials, dividing it by the average number of members reported to the NC Department of Insurance and multiplying this by 1,000. Thus, a denial rate of 20 means that the HMO denied 20 services for every 1,000 members. It is important to remember that HMOs deny services for many reasons. Some HMOs deny health care services because there are other services that can better meet the health care needs of the patient. Other HMOs deny services because they have stricter standards about what they consider appropriate health care services. Comparing denial rates across HMOs can help identify HMOs that are more likely to deny requested services. However, these rates will not show how the HMO will handle your particular medical needs. The non-certification rates should be read with some caution. The HMOs may not be reporting their data consistently. For example, there are some indications that some HMOs did not include all the denials of emergency services in their non-certification numbers. The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported.
  
  
• Appeal Rate per 1,000 Noncertifications. This is the average number of appeals for every 1,000 noncertifications. We calculated this number by dividing the number of first level appeals by the total number of noncertifications and then multiplying that number by 1,000. This appeal rate does not included second level grievances. The appeal rate may appear high if a plan has a low number of noncertifications. See "Number of Noncertifications" section to obtain the number of noncertifications for each plan.
  
  
• Percentage of Appeals Decided for the Members. This shows the percentage of appeals that were decided in favor of the member. While the success rate varies among HMOs, more than half of the appeals that patients filed last year were decided on behalf of the member. Part of the reason is that the members or their providers provided additional medical information which showed why the requested health services were appropriate. This data does not include the number of decisions that were pending at the time the numbers were reported.

Financial Data

• Total Revenues. This shows the HMO’s total annual revenues in 1998. HMOs earn money from the premiums paid per member and from other sources such as investment income. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees.
  
  
• Average Premiums per member per month. The premiums per member per month is an approximation of an average premium for each HMO. We calculated the average premiums by taking the total amount of premiums earned in 1998, and dividing it by the number of member months. While the actual premium charged to any individual will vary, the average premium per member per month gives an idea of whether a particular HMO generally has higher or lower premiums than other HMOs. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Premiums for plans that include Medicare enrollees may seem higher than other plans because of the higher premium costs for Medicare enrollees.
  
  
• Five-Year Premium Trends. This shows how much the average premiums per member per month has increased over the last five years. Looking at the premiums over five years is a better way to compare premiums across health plans than examining the premiums in any particular year. For example, a health plan may decide to keep their premiums low in order to attract members over the course of several years. If the premiums are too low, and do not cover actual expenses, then the health plan will have to raise rates in the future. A five-year historical perspective may yield better information about how one-plan compares to the others. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Premiums for plans that include Medicare enrollees may seem higher than other plans because of the higher premium costs for Medicare enrollees.
  
  
• Medical/Hospital Expenses per member per month. This shows about how much money the HMO spent on health-related expenses each month for its members in 1998. This is an average of all the health care spending among the members. In reality, an HMO may spend a lot more than the average on some members, and a lot less than the average on others. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees. Medical/hospital expenses for plans that include Medicare enrollees may seem higher than other plans because of the higher premium costs for Medicare enrollees.
  
  
• Medical-Loss Ratio. This is the percentage of premiums that was spent on health care expenses versus administrative costs or profits in 1998. An HMO that has a high medical-loss ratio - 90 percent or above - spends a greater percentage of its premium dollars on health care than does an HMO with a lower medical-loss ratio. Medical-loss ratios that are either too high or too low may indicate potential problems in the plan. An HMO that spends too much money on medical expenses (high medical loss ratio) may not have enough resources to administer the plan. As a result, providers may not get paid on time and members could have more difficulty reaching HMO staff to answer questions or solve problems. HMOs that consistently spend less of its money on health care (low medical-loss ratios) may not be providing appropriate medical care to their enrollees.
  
  The medical-loss ratio by itself is not enough to determine the quality of care provided under the plan. For example, a low medical-loss ratio does not necessarily indicate that members have problems obtaining needed care. An HMO could spend a lower percentage of its revenues on health care services because it enrolled healthier members, negotiated lower reimbursement rates from the providers, or charged higher premiums. Typically, new HMOs have lower medical-loss ratios because they have higher administrative start-up costs in comparison to other more established plans. Thus, medical-loss ratios should not be considered alone. They should be read in conjunction with other information about quality, use and the costs of health care services. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees.
  
  
• Five-Year Medical-Loss Ratio Trends. This shows the HMO’s medical loss ratios over the last five years. An HMO may have an artificially high or low medical loss ratio in any particular year. For example, a health plan that installs a new computer system may have higher administrative expenses that year, leading to a low medical loss ratio. A health plan that set very low premiums in a specific year could have a very high medical loss ratio. Thus, looking at the medical loss ratio over five years gives more accurate information about the amount of premiums spent on health care expenses versus administration and profit. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees.
  
  
• Operating Profit Margin. The operating profit margin shows whether an HMO made or lost money in 1998. The operating profit margin is the HMO’s operating income (total revenues minus health care and administrative expenses), divided by its total revenues. The operating profit margin reflects how well the company performed financially in the past year. Note: The numbers listed in parenthesis are negative numbers, which means that the HMO lost money that year. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees.
  
  
• Five-year operating profit margin trends. Five-year data may be a more useful source of data in examining a health plan’s financial outlook. The numbers listed in parenthesis are negative numbers, which means that the HMO lost money that year.
  
  Several NC HMOs lost money over the last several years. A health plan may be able to sustain losses over a few years, but may not be able to handle continual losses over longer periods of time. New HMOs generally lose money initially as they incur large start-up costs (relative to revenues) in order to develop the company. The five-year operating profit margin data will show trends over time. For example, it will show which plans have consistently lost money, and which plans are experiencing a short-term loss. The trend data also shows whether HMOs that have lost money in the past have taken steps to improve their bottom line. Financial data includes Medicare enrollees when applicable. Partners, QualChoice, United Healthcare and WellPath have Medicare enrollees.

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