COVENTRY/PRINCIPAL HEALTH CARE OF THE CAROLINAS
Updated 10/2000

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000. Coventry/Principal would not supply updated information.

HMO General Information
Background Information	Coventry/Principal Health Care of the Carolinas received its HMO license from the NC Department of Insurance and began operations on December 15, 1994. It is a for-profit corporation, owned by Coventry Health Care, Inc. a Delaware corporation.
Type of HMO	Coventry/Principal 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	Coventry/Principal’s most commonly purchased health plan provides members a choice of two options each time services are needed an HMO network option and a point-of-service option. Members who choose the HMO option must receive services from health care providers who contract with Coventry/Principal. Members who selection the point of service option received services from the provider of their choice. The point-of-service option has additional cost sharing requirements, and may not cover all the same services as the HMO option.
Accreditation	Coventry/Principal Health Care of the Carolinas 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 OCCI is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees	Coventry/Principal offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group") or Medicare recipients, although some Medicare beneficiaries may have supplemental HMO coverage through their employer. Coventry/Principal does offer HMO coverage to Medicaid recipients in Mecklenburg county.
Counties in which HMO has an Active Presence	Coventry/Principal has at least 25 commercial (group) HMO members at the end of 1998 in the following North Carolina counties Anson, Buncombe, Cabarrus, Catawba, Chatham, Cleveland, Durham, Orange, Rowan, Stanly, Union, Vance and Wake.
Customer Service Number	1-800-889-1947
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: Room and board in semi-private room. Private room covered when medically necessary. General nursing care. Use of equipment and supplies. Use of operating, recovery and treatment rooms. Intensive care and related hospital services. Anesthesia. Internal prosthetics. Medication. Services of physicians and ancillary medical personnel. Surgical procedures. Consultation with and treatment by specialists during hospitalization. Limits: Members who self-refer to the hospital for non-emergency care under the Point-of-Service option will have their care reviewed by Coventry/Principal.
Outpatient Services		Covers: X-ray, laboratory and diagnosis. Ambulatory surgery. Physician services, including surgical procedure, consultation with and treatment by specialists and services provided by other licensed medical professionals.
Emergency Care		General Guidelines: If you have a medical emergency, seek medical attention immediately from a hospital, physician’s office or some other emergency facility. Covers: Within Plan Service Area —Services for medical emergencies are covered for reasonable charges at hospitals within the Plan Service Area. Outside Plan Service Area: Coventry/Principal will cover emergency services provided by an out-of-area emergency room or physician. Your PCP will normally perform follow-up services. Payment is limited to treatment required before the member can safely return to the service area for necessary follow-up. Ground ambulance transportation to return member to a Coventry/Principal participating provider is covered when pre-authorized. Notification: You must notify Coventry/Principal about your medical emergency within 48 hours to ensure coverage of services. If you are unable to because of a medical condition, notification requirements shall be waived. If you seek care in the emergency room for a condition that is not determined to be a medical emergency, you will be responsible for payment of the emergency room and any associated bills.
Urgent Care		Covers: Urgent care within the service area. If a condition requiring urgent care develops while you are in the service area, you must call your PCP’s office for medical evaluation and instructions. Urgent care outside the service area - If a condition requiring urgent care develops while you are outside the service area, go to the nearest urgent care center, physician’s office or any other provider for treatment. Limits: You must notify Coventry/Principal within 48 hours, condition permitting. The condition must be a covered service and be retroactively approved by Coventry/Principal. Payment shall be limited to treatment required before the member can safely return to the service area for necessary follow-up. Cost Sharing: Copayments apply.
Ambulance		Covers: Ambulance services for medical emergencies only. Benefits for transportation by air ambulance are reimbursed at the cost of ground ambulance transportation.
Care for Students Outside of Service Area		Covers: Medical emergencies, allergen administration, physical therapy, medical care in an ambulatory setting, and other conditions that result in sudden onset of the symptoms for which the member cannot return home for treatment.
Non-Urgent Care Outside of Service Area		Excluded.
Professional Services
Professional Services (general)		Covers: Routine office visits, pediatric and well baby care, routine physicals, immunizations, allergy testing, allergy serum and the administration of injections. Cost-sharing: Copayments apply.
OB/GYN		Covers: OB/GYN services. A referral is not required for services of participating obstetrician/ gynecologist for health care services related to female reproductive system and breasts.
Diagnostic Procedures		Covered.
Therapeutic Treatment Services		Covers: Radiation, Chemo-therapy (Covered in full when referred to an in network provider for services.) Covers: Short term respiratory therapy with limits Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks that the member’s condition will not significantly improve.
Allergy Testing and Treatment		Covers: Allergy testing, allergy serum, and the administration of injections.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Pediatric and well-baby care, routine physicals, and annual gynecological examination. Excludes: Physical examinations for employment, school, camp, sports, licensing, insurance, adoption or marriage or other examination ordered by a third party.
Immunizations		Covered. Excludes: Immunizations for travel and employment.
Preventive Clinical Services		Covers: Mammograms, pap smears, and PSA (when recommended by a participating physician).
Other Health Promotion/Disease Prevention Activities		Covers: Health education services when provided in a participating physician’s office or other participating provider setting. Health education services include instructions on achieving and maintaining physical and mental health, and preventing illness and injury. Excludes: Nutritional counseling unless medically necessary and approved by Coventry/Principal. Excludes food or food supplements.
Diabetic Treatment		Covers: Medically necessary equipment, supplies, services, equipment, medications, and laboratory procedures.
Conception Services
Prenatal Care and Obstetrical Services		Covers: Pre- and post-natal care. Excludes: Maternity services provided outside the service area within three weeks of the estimated date of delivery unless prior authorization is given in writing by Coventry/Principal.
Family Planning		Covers: Family planning counseling, information on birth control, insertion and removal of intrauterine devices, fittings for contraceptive diaphragms, birth control pills and contraceptives prescribed to treat a medical condition. Also covers male or female elective surgical sterilization. Excludes: Prescription drugs, medicine, supplies or devices related to birth control. Genetic counseling that is not needed for diagnosis or treatment of genetic abnormalities is also excluded.
Abortion		Covers: Medically necessary abortions.
Infertility Services		Covers: Diagnosis and surgical treatment of involuntary infertility. Coverage includes X-rays, laboratory procedures and medication needed to evaluate fertility status. Excludes: Artificial insemination with donor semen, in vitro fertilization, and embryo transport procedures. Drug therapy for infertility such as Pergonal, Clomid, and other similar drugs is also excluded. Also excludes any medical services, prescription drugs, medicine, supplies or procedures related to reversal of voluntarily induced sterilization.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Excluded unless provided in a supplemental policy. With the purchase of a supplemental policy, covers: Inpatient care in a participating hospital or residential treatment facility. Cost-Sharing: Copayments apply. Excludes: Inpatient services for chronic mental health conditions including psychotherapy. Mental health services for mental retardation or autism after diagnosis. Vocational, marriage, and/or sex counseling Remedial education, including evaluation or treatment of learning disabilities, speech difficulties, etc. Individual treatment for smoking, weight loss or personal growth. Any services mandated by court order, or as a condition of parole or probation.
Mental Health Outpatient		Excluded unless provided in a supplemental policy. With the purchase of a supplemental policy, covers: Ambulatory care, including evaluation, crisis intervention and therapy. These services may include individual/group therapy or diagnostic evaluation and medical evaluations and medication management. Excludes: Mental health services for mental retardation or autism after diagnosis. Vocational, marriage, and/or sex counseling Remedial education, including evaluation or treatment of learning disabilities, speech difficulties, etc. Individual treatment for smoking, weight loss or personal growth. Any services mandated by court order, or as a condition of parole or probation.
Substance Abuse Inpatient		Excluded, unless purchased in a supplemental policy. Supplemental policy: Covers: Inpatient and partial inpatient hospital stays related to the treatment of substance abuse Limits: 30 days per calendar year and 2 admissions per lifetime for detoxification and rehabilitation Cost Sharing: 50% coinsurance applies for all substance abuse services
Substance Abuse Outpatient		Excluded, unless purchased in a supplemental policy. Supplemental policy: Covers: Group and individual treatment for substance abuse Limits: 20 visits per calendar year, 2 group sessions may be substituted for 1 individual session Cost Sharing: 50% coinsurance applies for all substance abuse services
Prescription Drugs and Medical Supplies
Prescription drugs		Covers: Prescription drugs and injectable medications used to treat a medical condition, and contraceptives are covered when purchased in a supplemental policy by group. Excludes: Experimental drugs, including those labeled "Caution — Limited by Federal Law to Investigational Use" and drugs found by the Food and Drug Administration to be ineffective. Also excludes Nicorette gum, Minoxidil lotion, fertility drugs, and appetite suppressants, including those such as Reducx.
Blood		Covers: Administration, storage and processing of blood and blood products. Excludes: Replacement of whole blood and blood products.
Medical Supplies		Covers: medically necessary supplies such as diabetic syringes and needles, crutches, casts, splints, and other corrective medical appliances, such as orthopedic braces. Excludes: Over-the-counter devices and/or supplies, such as ACE wraps, elastic supports, and soft cervical collars; sunglasses, corsets, clothing, disposable items, air mattresses, and needles and syringes. Also excludes purchase or rental of supplies of common household use such as exercise cycles, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or mattresses and waterbeds.
Insulin and Diabetic Supplies		Covered.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)		Covers: DME if it is primarily used to serve a medical purpose, can withstand repeated use, is appropriate for use in a member’s home and is on our durable medical equipment reference list. Limits: The combined total maximum benefit is limited to $1,000 per member per calendar year. Excludes: DME that does not serve a medical purpose, cannot be used in a member’s home, and is generally not useful to a person without illness, injury or disease.
Prosthetic Devices		Covers: Certain prosthetic devices, including external devices such as artificial limbs, eyes and breast following a mastectomy. Also covers internal devices such as hip prosthesis, lens implant and breast implant following a mastectomy. Limits: External devices are limited to one each per member per lifetime, except if a bilateral mastectomy is performed. Excludes: Dental prosthesis, bionics, special shoes, breast pumps and penile prostheses. Also excludes the replacement and repair of prosthetic devices unless deemed medically necessary by Coventry/Principal.
Orthotic Devices		Excluded.
Rehabilitative and Habilitative Services
Physical Therapy		Covers: Short term physical therapy to restore normal physical functions due to trauma, stroke or a surgical procedure. Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks of therapy that the member’s condition will not significantly improve.
Occupational Therapy		Covers: Short- term occupational therapy to restore normal physical functions due to trauma, stroke or a surgical procedure. Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks of therapy that the member’s condition will not significantly improve.
Speech Therapy		Covers: Short term therapy to restore speech loss or impairment due to trauma, stroke or a surgical procedure. Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks of therapy that the member’s condition will not significantly improve.
Pulmonary Therapy		Covers: Short-term pulmonary therapy. Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks that the member’s condition will not significantly improve.
Chiropractic		Excludes: Chiropractic care unless prior authorization is given by your PCP and Coventry/Principal.
Cardiac Rehabilitation		Covers: Cardiac rehabilitation therapy. Limits: Therapy is limited to conditions that are expected to show significant improvement in 60 days. Benefits for therapy and/or treatment will be discontinued if it is determined within the first two weeks that the member’s condition will not significantly improve.
Other Therapy Services		Covers: Pain management therapy with prior approval.
Skilled Nursing Facility		Covers: Skilled nursing facility services when authorized in place of acute care hospitalization. Coverage includes medical supplies, equipment, drugs, and biologicals ordinarily furnished by the skilled nursing facility. Excludes: Custodial care, nursing home care, rest cures and rest home care, along with all related services.
Home-Based Services
Home Health		Covers: Home health services when they are ordered by a physician and approved by the PCP. To be covered, the following conditions must be met: The services can only be performed by a licensed nurse, physical therapist, speech therapist, or occupational therapist. Services must be a substitute for hospitalization. Part-time intermittent services are needed. A treatment plan has been established and periodically reviewed by the ordering physician. The agency providing the services is Medicare certified and licensed by the state of location. Coventry/Principal must authorize the services.
Private Duty Nursing		Covers: Special or private duty nursing when determined medically necessary through case management.
Hospice		Covers: Hospice provided by a state- licensed hospice. The member must, in the judgement of the participating physician, have a life expectancy of six months or less. Excludes: Health care, visits, medical equipment or supplies that are not included in Coventry/Principal’s recommended plan of treatment. Services in the member’s home outside the Coventry/Principal service area. Financial and legal counseling. Any service for which the hospice does not customarily charge the member, or his or her family. Reimbursement for volunteer or spiritual counseling.
Transplants and Dialysis
Transplants		Covers: Kidney, cornea, heart, liver, and bone marrow, when determined that medically necessary and specific criteria are met. Limits: Transplants must be approved by Coventry/Principal and performed at a facility approved by Coventry/Principal. Donor expenses: Professional and facility costs for donor are covered if other sources of reimbursement are unavailable, regardless of membership. Organ preparation and transportation are also covered. Excludes: The cost of any care arising from an organ donation by a member when the recipient is not a member. Also, excludes any transplant procedure that is performed in a facility that has not been designated by the Medical Director as an approved transplant facility.
Dialysis		Covered.
Other Services
Dental		Covers: Oral surgical services to restore facial structures other than teeth. For example, Coventry/Principal covers treatment for jaw fractures or laceration of the mouth, tongue or gums. Also covers treatment for TMJ if caused by disease or accident. Excludes: Crowns, bridges, dentures, or other dental prosthetic devices. Dental restorative care. Periodontal care. Treatment of impacted wisdom teeth. Orthodontics. Orthognathic surgery, along with hospital and professional services and supplies associated with such care. Treatment for TMJ unless caused by disease or accident. Any treatment for TMJ, which requires prosthesis to be placed directly on the teeth, is excluded. Preventive dental services are excluded unless provided in a Supplemental Benefit Expansion.
Vision		Covers: The first pair of corrective lenses following cataract surgery performed while a member of Coventry/Principal. Excludes: Routine vision examinations, eyeglasses, and corrective lenses. Also excludes radial keratotomy, surgeries to correct myopia, and eye exercises. Eye examinations needed to prescribe eyeglasses or contact lenses are also excluded, unless vision care was purchased through a supplemental policy. With the purchase of a supplemental policy: Covers: Medically necessary routine eye examinations. Excludes: Drugs or other medication not used for the purpose of vision examination.
Hearing		Excludes: Hearing aids and hearing related implants including cochlear implants. Also excludes audiometric testing and expenses for hearing aids.
Foot Care		Excluded. Also excludes services provided by podiatrists unless prior authorization is given by the PCP and Coventry/Principal.
Weight Loss		Excludes: Weight reduction services such as therapy, surgery, hospitalization, or diet programs. Excludes tests, exams or services for diet programs, such as Optifast, Nutri-system and other similar diet programs. Also excludes surgical procedures for the treatment of obesity, such as intestinal bypass surgery, stomach stapling, balloon dilation, wiring of the jaw and procedures of similar nature. Excludes care for complications from these surgical procedures.
Smoking Cessation		Excluded.
Growth Hormones		Excludes: Growth hormones that are not medically necessary.
Alternative Therapies		Excludes: Acupuncture, biofeedback, hypnotherapy, and sleep therapy.
Reconstructive/Cosmetic Surgery		Covers: Repair of disfigurement resulting from an injury, reconstruction incidental to surgery and surgery that substantially improves functioning of any malformed body part. Also covers removal of skin lesions that interfere with normal body functions or if malignancy is suspected. Limits: Reconstructive surgery will be covered only if the cause occurred while the member was enrolled in Coventry/Principal. Excludes: Cosmetic surgery, except for services to correct a congenital defect or an anomaly for newborn, foster or adoptive children.
Non-Emergency Transportation		Covers: Reasonable travel and lodging expenses for a member or a dependent child. Also covers a parent or guardian accompanying a minor child for covered services performed outside of the service area.
Excluded Services
Experimental or Investigational Services		Excluded.
Services Not Considered Medically Necessary		Excluded.
Non-emergency services Rendered in the Emergency Room		Excluded.
Commonly Excluded Services		See List of Common Exclusions
Definitions
Medically necessary		Meets statutory definition.
Experimental or Investigational		Any treatment, procedure, facility, equipment, drug, device or supply another word for supply that Coventry/Principal determines is not accepted as standard medical treatment for the condition being treated. Also, any item of technology requiring federal or other government agency approval which has not been granted at the time of treatment.
Emergency		Meets statutory definition of emergency.
Urgent Care		An unexpected illness or injury which is not life-threatening but requires prompt medical attention. Examples include fractures, lacerations, or severe abdominal pain.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as Primary Care Provider		Any duly licensed doctor of medicine or osteopathy in the medical fields of internal medicine, family practice and pediatrics, or whom the Coventry/Principal Health Plan specifies as a PCP.
What Happens if Member Fails to Choose a PCP?		If you fail to choose a PCP, a PCP located in the same or nearby zip code location as the member’s home address is assigned for them.
Process to Change PCP		A member may change his or her PCP by contacting the Member Services Department and requesting reassignment to a different PCP. The change will take effect within 31 days of the request. A member may change his/her PCP no more than twice a year, unless extenuating circumstances exist.
referrals to Specialists		If you are using the HMO option, you must obtain a referral and/or authorization from your PCP before receiving services from a specialist, hospital, or other provider. After you have obtained a referral and/or authorization from your PCP, you may make an appointment with that specialist. No referral is needed if you are using the point-of-service option.
Can Specialists Serve as PCP?		No.
Non-Emergency Hospital Preauthorization Requirements		Your PCP will arrange for non-emergency hospital services in a participating hospital. Either your PCP will admit you or you will be referred to a participating physician who will manage your inpatient care in coordination with your PCP. Your physician will give you instructions about which hospital to go to, including the date and time of arrival. The admitting physician is responsible for notifying Coventry/Principal of a member’s admission. The member may wish to verify with the physician that approval has been obtained prior to your planned admission. Coventry/Principal may also require you to obtain a second surgical opinion. Coventry/Principal will notify your PCP and make the necessary arrangements for the second surgical opinion with an appropriate board certified specialist who is neither associated with nor in practice with the Physician who recommended the surgery or who will perform the surgery.
Appeal and Grievance Procedures
Informal Reconsideration		Requesting an informal reconsideration: A member may file a complaint informally to a Coventry/Principal Member Services Representative by telephone, in person or in writing. Complaints will be handled as quickly as possible. Requesting an informal reconsideration of a non-certification: Reconsiderations will be conducted between the provider and a medical doctor designated by the Plan. The meeting will be scheduled within 72 hours after all of the necessary information is received and a decision will be rendered within 48 hours after the meeting. All appropriate medical information must be received 24 hours prior to the meeting between the medical director and the provider.
First Level Non-Certification Appeal Provisions		Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to Coventry/Principal within 60 days of the date non-certification. Members will receive a response from Coventry/Principal within 30 days of Coventry/Principal’s 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: Decision notification will be sent to the member within 30 or 31 days of Coventry/Principal’s receipt of the grievance hearing request.
Second-Level Grievance Hearings (Covers Second-Level Appeals and Grievances)		Follows statutory definition. Note: Requests for second level grievance hearings must be made following a first level grievance or appeal decision. No time limitations are specified in the Evidence of Coverage. The second level review meeting will be held within 45 days of Coventry/Principal’s receipt of a request for a second level grievance review. Member will be notified of the decision within 7 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. The member may also pursue normal remedies of law. Such a suit or proceeding must be commenced not later than 3 years after the date of notice of final determination if given to the member.
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 Coventry/Principal does not provide benefits for the healthcare service performed or being requested, as outlined in the member’s Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1998 (Financial Report, # 10)		21,576
Member Months (1998) (Financial Report, #11)		251,140
Average 1998 Monthly Enrollment (Member Months/12)		20,928
Percentage of Change in Average Monthly Enrollment between 1997-1998		36.2%
Five-year Average Enrollment Trends		1998: 20,928 1997: 15,369 1996: 6,129 1995: 418 1994: N/A
Percentage of Groups that Disenrolled (December 31, 1997-December 31, 1998)		33%
Percentage of Members that Disenrolled (December 31, 1997-December 31, 1998)		0%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1997 — Dec. 31, 1998)		8%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1997 — Dec. 31, 1998)		0%
Utilization Review Information
Number of Reviews Requested, 1998		16,993
Review Rate per 1,000 Members, 1998		812
Percentage of Noncertifications, 1998		3.76%
noncertification Rate per 1,000 Members, 1998		30.53
appeal Rate per 1,000 Noncertifications, 1998		82.94
Percentage of Appeals Decided for the Members, 1998		37.50%
Financial Data
Total 1998 Revenues (Financial Report, #6)		$29,526,109
Average Premium per member per month (1998) (Financial Report, #5 / #11)		$115.73
Five-Year Premium per member per month Trends		1998: $115.73 1997: $99.65 1996: $97.60 1995: $111.39 1994: $N/A
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1998		$115.54
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1998		99.8%
Five-year medical loss ratio Trends		1998: 99.8% 1997: 95.1% 1996: 99.9% 1995: 90.0% 1994: N/A
Operating profit margin (Financial Report, #9 / #6)		(21.2%)
Five-year Operating Profit Margin Trends		1998: (21.2%) 1997: (29.2%) 1996: (51.0%) 1995: (280.5%) 1994: N/A
Sources of Information
Source of Information		HMO Plus Point of Service PHC-3201-NC-PLUS-11/94; 1998 Annual Financial Report; NC Department of Insurance Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC Department of Insurance, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on Utilization Review and Appeals and Grievances from NC Department of Insurance.

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