PRUDENTIAL HEALTH CARE PLAN

HMO General Information
Background information	Prudential Health Care Plans received its HMO license from the State of Texas on May 21, 1976. It began its North Carolina operations on March 11, 1985. Prudential Health Care Plans is a for-profit corporation, and is not incorporated in North Carolina. It was recently purchased by Aetna, Inc., a Connecticut corporation.
Type of HMO	Prudential Health Care Plan operates an IPA/group model HMO. That means that it contracted directly with physicians in the community or with networks of physicians, as well as having an exclusive contractual relationship with a medical group.
Types of Products	Prudential’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. Prudential Health Care Plan does not offer a point-of-service product.
Accreditation	Prudential received a provisional accreditation from the National Committee for Quality Assurance (NCQA). NCQA looks at five categories in its accreditation process: access and services, qualified providers, staying healthy, getting better, and living with illness. An HMO seeking accreditation is evaluated on how well it meets NCQA’s standards in each of these areas. HMOs that fully meet NCQA’s standards receive a Commendable status. Those that meet most of NCQA standards receive an Accredited status. Provisional accreditation may be given for plans that meet some, but not all, of NCQA standards. Health plans that fail to meet NCQA’s requirements during the review will have their accreditation request Denied. A health plan’s accreditation status gives an idea of the quality of care provided by the plan as a whole. However, NCQA’s accreditation does not guarantee the quality of care provided to any individual member.
Enrollees	Prudential offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group"), Medicaid or Medicare recipients, although some Medicare beneficiaries may have supplemental HMO coverage through their employer.
Counties in which HMO has an Active Presence	Prudential has at least 25 commercial (group) HMO members at the end of 1998 in the following North Carolina counties: Alamance, Alexander, Anson, Burke, Cabarrus, Caldwell, Catawba, Chatham, Cleveland, Craven, Cumberland, Durham, Franklin, Gaston, Granville, Guilford, Harnett, Iredell, Johnston, Lee, Lincoln, Mecklenburg, Nash, New Hanover, Onslow, Orange, Person, Pitt, Randolph, Rowan, Stanly, Union, Vance, Wake, Wayne and Wilson.
Customer Service Number	1-800-643-6309 (Charlotte) 1-800-778-8857 (Raleigh)
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: Semi-private room and board (private rooms covered if approved by Prudential). All normal daily services, supplies, and non-professional services furnished by the hospital. Anesthetics and their administration. Excludes: Services and supplies for scholastic education or vocational training of patient.
Outpatient Services		Covers: Anesthetics and their administration as well as all other supplies and nonprofessional services furnished by the hospital for medical care in it.
Emergency Care		Covers: Emergency care is covered at 100% (less copayment). Notification Requirements: Prior authorization of emergency services is not required if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Limits: A term delivery of a baby, 36 weeks or more, by vaginal or by cesarean section is not a medical emergency. This applies inside or outside the service area Cost Sharing: copayment applies.
Urgent Care		Covers: Emergency care is covered at 100% (less copayment). Excludes: Routine care and follow-up care out-of-area. Notification Requirements: Prior authorization is not required if a prudent layperson acting reasonably would have believed that an emergency medical condition existed.
Ambulance		Covered.
Care for Students Outside of Service Area		Covered: Emergency care is covered at 100% (less copayment). Notification Requirements: Prior authorization is not required if a prudent layperson acting reasonably would have believed that an emergency medical condition existed.
Non-Urgent Care Outside of Service Area		Not covered unless rider is purchased. Covers ( with Institutes of Quality rider): Care outside of the plan’s service area may be provided by physicians with whom Prudential contracts to provide specific procedures. Limits: Patient must be referred by PCP or Specialty Care Physician, approved by Prudential, and be verified as a candidate for the recommended procedure through a pre-screening evaluation conducted by the Institute of Quality.
Professional Services
Professional Services (general)		Covers: Office visits. Cost Sharing: Copayment applies.
OB/GYN		Covers: OB/GYN services. A referral is not required for services of participating obstetrician/ gynecologist for females age 13 or older related to female reproductive system and breasts.
Diagnostic Procedures		Covers: X-ray and lab exams.
Therapeutic Treatment Services		Covers: Chemotherapy, and treatment by X-ray, radium or any other radioactive substance. Also covers inhalation therapy.
Allergy Testing		Covers: Allergy serum. Cost Sharing: Copayments apply for eligible services and supplies furnished for an allergy workup.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Well-baby care and routine office visits. Excludes: Physical examinations solely required in connection with insurance, licensure, school, employment, for travel outside the US, or for similar reasons. Cost Sharing: Copayment applies.
Immunizations		Covered with some limitations. Excludes: Immunizations solely required in connection with insurance, licensure, school, employment, for travel outside the US, or for similar reasons. Cost Sharing: Copayment applies.
Preventive Clinical Services		Covers: Mammograms, pap smears, and PSA (when recommended by a participating physician). Cost Sharing: Copayment applies.
Other Health Promotion/Disease Prevention Activities		Covers: Instruction in personal health care and information about Prudential’s eligible services. These include recommendations on generally accepted medical standards for the use and frequency of such services. Excludes: Training in the activities of daily living, unless directly related to treatment of a sickness or injury that resulted in a loss of an ability to perform those activities.
Diabetic Treatment		Covers: medically appropriate and necessary services including diabetes outpatient self-management training and educational services, and laboratory procedures to treat diabetes.
Conception Services
Prenatal Care and Obstetrical Services		Covers: Pre-natal and post-natal care. Excludes: For pregnancy, services and supplies furnished in connection with a term delivery (36 weeks or more) outside the service area.
Family Planning		Covers: Voluntary family planning and different types of prescribed birth control, such as diaphragms, the Pill, Depo-Provera, IUDs, Norplant, etc. Limits: 90-day supply per initial prescription or refill. Cost Sharing: Copayments apply.
Abortion		Covers: Medically necessary abortions.
Infertility Services		Covers: Artificial insemination and services and supplies that are not specifically excluded in the Evidence of Coverage. Excludes: Services and supplies furnished in connection with any procedures that involve harvesting, storage and/or manipulation of eggs or sperm, such as in vitro fertilization, embryo transfer, embryo freezing, Gamete Intra-fallopian Transfer (GIFT), and Zygote Intra-fallopian Transfer (ZIFT). Also excludes drug therapy for infertility that involve non-FDA-approved indications, or non-standard dosages, length of treatment, or cycles of therapy. Excludes reversal of a previous voluntary surgical procedure to induce fertility.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Covers: Services and supplies for up to 30 days of a person's inpatient hospital stay in a calendar year. Limits: Services and supplies for the treatment of mental, psychoneurotic and personality disorders must be furnished or authorized by a Prudential Mental Health Coordinator. Each day of a hospital inpatient stay counts as 2 days of intermediate facility care; each 2 days of intermediate facility care counts as 1 day of a hospital inpatient stay. Cost Sharing: Copayments apply.
Mental Health Outpatient		Covers: Physician Visits: Up to 20 50-minute physicians' visits (or the equivalent) that may be necessary for short-term evaluative or crisis intervention mental health services or both. Intermediate Care Facility: Services and supplies for up to 60 days of a person's inpatient stay in a calendar year. This care means continuous treatment at a facility in the range of 3-12 hours within a 24-hour period. Limits: Services and supplies for the treatment of mental, psychoneurotic and personality disorders must be furnished or authorized by a Prudential Mental Health Coordinator. Each day of a hospital inpatient stay counts as 2 days of intermediate facility care. Each 2 days of intermediate facility care counts as one day of a hospital inpatient stay. Services not available to promote development beyond any level of function previously demonstrated. Cost Sharing: Copayments apply. Excludes. Educational services, such as treatment for learning disabilities, instruction in scholastic skills (i.e.: reading and writing) and preparation for an occupation.
Substance Abuse Inpatient		Covers: Up to 20 days of a hospital inpatient stay in a calendar year for rehabilitative services for alcoholism or drug abuse. Benefits for such services cannot exceed $2,500 in a calendar year. Services, including referral services for medical care in connection with detoxification. This does not include rehabilitative services. Services and supplies for medical care and treatment of a sickness that is a direct result of alcoholism or drug abuse. Limits: Services and supplies for the treatment of abuse of or addiction to alcohol or drugs must be furnished or authorized by a Prudential Mental Health Coordinator.
Substance Abuse Outpatient		Covers: Services, including referral services for medical care in connection with detoxification. This does not refer to rehabilitative services. Services and supplies for medical care and treatment of a sickness that is a direct result of alcoholism or drug abuse. Up to 20 50-minute physician visits in a calendar year for alcoholism or drug abuse rehabilitative services. Limits: Services and supplies for the treatment of abuse of or addiction to alcohol or drugs must be furnished or authorized by a Prudential Mental Health Coordinator. Cost Sharing: Copayments apply.
Prescription Drugs and Medical Supplies
Prescription Drugs		Covers: Inpatient drugs and outpatient prescription drugs listed in the formulary that are prescribed by a participating physician and dispensed at a participating pharmacy. Covers injectables ordered & administered by a participating provider including injectable insulin. Limits: A 3-day supply can be obtained from a non-participating pharmacy if ordered in connection with a medical emergency, or if a physician orders immediate use of the drugs and a participating pharmacy is not open at the time. Covered supply is limited, per prescription or refill, to: 90-day supply of an oral contraceptive or a maintenance drug. 30-day supply of tablets, capsules and liquids to be taken orally. 60 milliliters or 1 manufacturer’s smallest standard package size of topical solution or lotion, or 14-day supply of rectal or vaginal medication. 1 manufacturer’s standard package unit containing no more than 60 grams of topical ointment or cream. 1 vial containing no more than 15 milliliters of any otic or opthalmic product. 2 manufacturer’s smallest standard package units of a nasal or oral inhibiter. 3 manufacturer’s standard 10 milliliter vials of insulin. Cost Sharing: Copayments apply. Excludes: Brand name drugs when the initial prescription or refill is for a generic drug and the generic drug is available.
Blood		Covers: Blood and blood plasma not replaced by or for the patient including administration of blood and blood plasma. Collection and storage of autologous blood if connected to a surgical procedure authorized by the member’s PCP, for the treatment of psychoneurotic and personality disorders. Also authorized in conncection with the treatment of abuse or addiction to alcohol or drugs when authorized by a Mental Health Coordinator. Blood storage is limited to three months.
Medical Supplies		Covers: Nondurable medical supplies, such as surgical dressings and casts, blood and urine testing supplies, syringes, lancets and prep solution. Also covers oxygen and rental of equipment for use of oxygen.
Insulin and Diabetic Supplies		Covers: 3 manufacturer’s standard 10 milliliter vials of insulin, when ordered by a participating physician and obtained from a participating pharmacy (per order or refill). Limits: Preauthorization required.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment		Covers: Rental or purchase of DME, including repair and necessary maintenance not provided under a manufacturer’s warranty or a purchase agreement. Limits: Services or supplies that exceed $1,000 for all DME purchased during a calendar year. Also excludes replacement of DME unless determined to be medically necessary.
Prosthetic Devices		Covers: Certain artificial aids and appliances that are ordered by a participating physician including, artificial limbs, larynx and eyes, heart pacemakers, splints, trusses and braces.
Orthotic Devices		Covers: Certain artificial aids and appliances that are ordered by a participating physician including, artificial limbs, larynx and eyes, heart pacemakers, splints, trusses and braces.
Rehabilitative and Habilitative Services
Physical Therapy		Covers: Limited to short-term services that are provided within 60 days of the date therapy begins for any one condition. Excludes: Maintenance services.
Occupational Therapy		Covers: Limited to short-term services that are provided within 60 days of the date therapy begins for any one condition. Excludes: Maintenance services.
Speech Therapy		Covers: Limited to short-term services that are provided within 60 days of the date therapy begins for any one condition. Services must be furnished by a qualified speech therapist and be for one of the following purposes: To restore speech after a loss or impairment. The loss or impairment must not be caused by a mental, psychoneurotic or personality disorder. To develop or improve speech, after surgery to correct a defect that existed at birth and impaired or would have impaired the ability to speak. Excludes: Maintenance services, therapy to correct pre-speech deficiencies, and therapy to improve speech skills that have not fully developed.
Pulmonary Therapy		Covers: If ordered by a participating provider and is medically necessary.
Chiropractic		Covered under therapy benefits (short term). Excludes: Services or supplies in connection with spinal manipulation.
Cardiac Rehabilitation		Not listed in Evidence of Coverage.
Skilled Nursing Facility		Covers: Room and board; normal daily services, supplies, and non-professional services. Limits: Limited to 100 days at a time. Nursing home stays must be separated by more than three months. A Prudential physician must recommend the nursing home stay for either recovery from a sickness or injury that resulted in a prior hospital stay; or in place of a hospital stay that would be required in the absence of these services. Excludes: Custodial care.
Home-Based Services
Home health		Covers: Registered nurse provided or supervised services furnished as part of a treatment plan approved by the Medical Director. This applies while the member is under a participating physician’s care.
Private Duty Nursing		Covered. See Skilled Nursing.
Hospice		Covers: Room and board and other services furnished by hospice. Also covers counseling services for family provided within 3 months of the death of a hospice patient. All hospice services must be provided within 7 months of the patient entering or re-entering the hospice care program. Limits: Must be authorized by a participating physician. Services and supplies cannot exceed $7400. Counseling services may not exceed $200.
Transplants and Dialysis
Transplants		Covers (for recipient): Services for surgical procedures and for other medical care in connection with the following procedures: Bone marrow, kidney, pancreas, SPK (Simultaneous Pancreas and Kidney), cornea, heart, lung, heart-lung, liver (for children less than age 18 with Biliary Atresia). Also covers allogenic bone marrow for the following conditions: aplastic anemia, leukemia, severe combined immunodeficiency disease (SCID), or Wiskott-Aldrich Syndrome. Covers (for live donor): Any of the above services and supplies that are required for a live donor as a result of a covered surgical transplant procedure. These services and supplies must not be covered by any other plan or arrangement.
Dialysis		Covered.
Other Services
Dental		Covers: Services for treatment or removal of a tumor. Physicians’ services or x-ray exams for the treatment of injury to natural teeth. Treatment includes the replacement of those teeth. Physicians’ services or x-ray exams made for diagnostic, therapeutic or surgical procedures involving the bones or joints of the jaw, face or head. For these purposes, therapeutic procedures shall include splinting and the use of intraoral prosthetic appliances to reposition the bones. Excludes: Orthodontic braces, crowns, bridges, dentures, treatment for periodontal disease, dental roof form implants, or root canals. Also excludes physicians’ services and x-ray exams involving one or more teeth, the tissue or structure around them, the alveolar process or the gums.
Vision		Covers: Vision screening to determine the need for vision correction for persons less than age 18. Also covers initial replacements for loss of the natural lens. Limits: Corrective appliances and artificial aids, including but not limited to, eyeglasses or lenses of any type. Excludes: Exams to determine the need or changes for eyeglasses or lenses of any type. Excludes eye surgery such as radial keratotomy, when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring).
Hearing		Covers: Screening to determine the need for hearing correction for persons less than age 18. Excludes: Corrective appliances and artificial aids, including but not limited to, hearing aids and cochlear implants. Also excludes exams to determine the need for hearing aids, or the need to adjust them.
Foot Care		Covers: Open cutting operation of the food and nail roots, the removal of part or of one or more nail roots; and services furnished in connection with treatment of a metabolic or peripheral vascular disease or of a neurological condition. Excludes: Services for a weak, strained, flat, unstable or imbalanced foot in the absence of localized sickness or injury or for a metatarsalgia or bunion. One or more corns, calluses or toenails.
Weight Loss		Covers: Severe obesity that is life threatening or obesity that has been clinically demonstrated to have an adverse effect on a concurrent sickness. Excludes: Services and supplies that are furnished in connection with any weight loss program. Also excludes food supplements used to lose weight.
Smoking Cessation		Covers: Treatment if the member is undergoing medical care for a concurrent sickness and smoking has been clinically demonstrated to have an adverse effect. Treatment if the member completes the smoking cessation program. Limits: 1 program per lifetime.
Growth Hormones		Covered.
Alternative Therapies		Covers: Alternative therapies, including, but not limited to, medical biofeedback treatment, acupuncture and hypnotic therapy if approved by Prudential.
Reconstructive/Cosmetic Surgery		Covers: Surgery to correct an injury. Surgery to treat a condition that impairs the function of a bodily organ. Reconstructive surgery after surgery has been performed to treat a disease. Surgery to treat a congenital defect. Excludes: Services and supplies, such as cosmetic surgery performed mainly to change a person’s appearance. This includes surgery performed to treat a mental, psychoneurotic or personality disorder through change in appearance.
Non-Emergency Transportation		Covers: Reasonable transportation and hotel accommodations (as determined by Prudential) for travel required when a PCP or Mental Health Coordinator refers the member to a health care provider located outside the service area. Transportation and hotel accommodations for a parent accompanying a minor child. Travel for a person to accompany the covered patient to an Institute of Quality. Expenses for family member or friend to remain there for all or a portion of the patient’s stay at an Institute of Quality during pre-screening evaluation, a procedure, or a follow-up exam. Transportation, hotel accommodations and meals are also eligible for coverage relating to Institute of Quality visits. Limits: All travel arrangements must be approved in advance by Prudential. For travel associated with an Institute of Quality, the Institute must be 50 or more miles from home, and the itinerary must be pre-approved by Prudential. Excludes: Travel by the member for personal comfort or convenience. Personal and convenience items. Services and supplies in connection with the repair or maintenance of a car. Services and supplies to maintain the travel companion’s home during the patient’s stay, such as child care, house sitting and pet kennel care. Reimbursement of wages lost by the travel companion.
Excluded Services
Experimental or Investigational Services		Excluded.
Services Not Considered Medically Necessary		Services and supplies that are not medically necessary (i.e., "needed or not appropriately provided") are excluded.
Non-Emergency Services Rendered in the Emergency Room		Covers: Emergency Care is covered at 100% (less copayment). Limits: No prior authorization is required if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. If Prudential is not notified once the covered person is stabilized, no benefits will be provided thereafter unless authorized by a primary care provider. Cost Sharing: Copayments apply.
Commonly Excluded Services		See list of common exclusions.
Other		See list of common exclusions.
Definitions
Medically Necessary		Services or supplies are covered: for the diagnosis, treatment, or cure of a health condition, illness, injury or disease; and not for experimental, investigational or cosmetic purposes; and necessary for and appropriate to the diagnosis, treatment, cure or relief of a health condition, illness, injury, disease or its symptoms; and within generally accepted standards of medical care in the community; and not solely for the convenience of the insured, the insured’s family or the provider.
Experimental or Investigational		A supply or service is considered experimental or investigational if one or more of the following is true: The service or supply is under study or in a clinical trial to evaluate its toxicity, safety or efficacy for a particular diagnosis or set of indications. Clinical trials include, but are not limited to, Phase I, II, and III clinical trials. The prevailing opinion within the appropriate specialty of the US medical profession is that the services or supply needs further evaluation for the particular diagnosis or set of indications before it is used outside clinical trials or other research settings. This item will be determined to be true based on published reports in authoritative medical literature; and regulations, report, publications, and evaluations issued by government agencies. In the case of a drug, device or other supply that is subject to FDA approval: It does not have FDA approval; or It has FDA approval only under its treatment investigational new drug regulation or a similar regulation; or It has FDA approval, but it is being used for an indication or at a dosage that is not an accepted off-label use. The provider’s institutional review board acknowledges that the use of the service or supply is experimental or investigational and subject to that board’s approval. The provider’s institutional review board requires that the patient, parent or guardian give an informed consent stating that the service or supply is experimental or investigational or part of a research project or study; or federal law requires such consent. Research protocols indicate that the service or supply is experimental or investigational. This item applies for protocols used by the patient’s provider as well as for protocols used by other providers studying substantially the same service or supply. Note: A drug prescribed for cancer treatment will not be considered experimental or investigational if it is (a) approved by the FDA, and (b) has been proven effective and accepted for the treatment of the specific type of cancer for which the drug has been prescribed. It must be recommended by one of the following: The American Medical Association Drug Evaluators, The American Hospital formulary Service Drug Information, or The United States Pharmacopoeia Drug Information.
Emergency		A medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, or by acute symptoms developing from a chronic medical condition that would lead a prudent layperson, possessing an average knowledge of health and medicine, to reasonably expect the absence of immediate medical attention to result in any of the following: Placing the health of an individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part. Some examples of "medical emergency" include: apparent heart attack, including but not limited to, severe crushing chest pain radiating to the arm and jaw; cerebral vascular accidents (stroke); severe shortness of breath or difficulty in breathing; severe bleeding; sudden loss of consciousness; convulsions; severe or multiple injuries, including obvious fractures (broken bones); severe allergic reactions; cyanosis (a bluish discoloration of the skin caused by a lack of adequate oxygen in the blood); apparent poisoning.
Urgent Care		Plan does not have a specific definition for this term.
Other		Needed and Appropriately Provided: A service or supply will be considered both "needed and appropriately provided" if Prudential determines that: It is furnished or authorized by a participating physician for the diagnosis or the treatment of a sickness or injury or for the maintenance of a person's good health. The prevailing opinion within the appropriate specialty of the US medical profession is that it is safe and effective for its intended use, and that its omission would adversely affect the person's medical condition. It is furnished by a provider with appropriate training, experience, staff and facilities to provide services or supplies. Prudential will determine whether these requirements have been met based on: published reports in authoritative medical literature; regulations, reports, publications or evaluations issued by government agencies; listings in certain drug compendia; and other authoritative medical sources. According to Prudential, "needed and appropriately provided" does not vary or differ from "medically necessary".
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of Providers Who Can Serve as a Primary Care Provider (PCP)		A primary care provider includes medical specialties, such as internal medicine (general), pediatrics, family practice, and, for the purpose of providing obstetrical or gynecological services or procedures for females age 13 and older only, obstetrics/gynecology.
What Happens if Member Fails to Choose a PCP?		Not listed in Evidence of Coverage.
Process to Change PCP		Call Member Services to request change.
referrals to Specialists		Your PCP must arrange for referrals to a medical specialist.
Can Specialists Serve as PCP?		No.
Non-Emergency Hospital Preauthorization Requirements		Preauthorization required. Must meet definition of medical necessity.
Appeal and Grievance Procedures
Informal Reconsideration		Follows statutory definition.
First-Level Noncertification Appeal Provisions		Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to Prudential. No time limitations are specified in the Evidence of Coverage. Members will receive a response from Prudential within 30 days of the Prudential’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: Members or their representatives must file a grievance with Prudential within 60 days of the incident or grievance. Members will be notified of the decision within 30 days of Prudential’s receipt of the grievance.
Second-Level Grievance Hearings (Covers 2nd 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 Prudential’s 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 NC Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes		The appeal and grievance process does not apply to the following: Any decision based solely on the fact that Prudential does not provide benefits for the health service performed or requested, as outlined in the Evidence of Coverage.
Enrollment Trends
Enrollment on December 31, 1998 (Financial Report, # 10)		2,117,562
Member Months (1998) (Financial Report, #11)		24,290,550
Average 1998 Monthly Enrollment (Member Months/12)		2,024,213
Percentage of Change in Average Monthly Enrollment between 1997 - 1998		16.8%
Five-year Average Enrollment Trends		1998: 2,024,213 1997: 1,732,597 1996: 1,544,313 1995: 1,330,942 1994: 1,164,486
Percentage of Groups that Disenrolled (December 31, 1997-December 31, 1998)		5%
Percentage of Members that Disenrolled (December 31, 1997-December 31, 1998)		32%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1997 — Dec. 31, 1998)		5%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1997 — Dec. 31, 1998)		4%
Utilization Review Information
Number of Reviews Requested, 1998		30,708
Review Rate per 1,000 Members, 1998		441
Percentage of Noncertifications, 1998		1.0%
Noncertification Rate per 1,000 Members, 1998		4.42
Appeal Rate per 1,000 Noncertifications, 1998		379.87
Percentage of Appeals Decided for the Members, 1998		59.46%
Financial Data
Total 1998 Revenues (Financial Report, #6)		$3,575,097,524
Average Premium per member per month (1998) (Financial Report, #5 / #11)		$145.21
Five-year Premium per member per month Trends		1998: $145.21 1997: $137.11 1996: $131.77 1995: $129.00 1994: $128.73
Medical/Hospital Expenses per member per month (Financial Report, #7 / #11), 1998		$130.50
Medical Loss Ratio (% Premiums Spent on Medical/Hospital expenses) (Financial Report, #15), 1998		89.9%
Five-year medical loss ratio Trends		1998: 89.9% 1997: 89.3% 1996: 85.7% 1995: 83.6% 1994: 80.3%
Operating profit margin (Financial Report, #9 / #6)		(3.3%)
Five-year Operating Profit Margin Trends		1998: (3.3%) 1997: (5.2%) 1996: (5.3%) 1995: (0.6%) 1994: 2.2% Color
Sources of Information
Source of Information		Certificate of Coverage for Prudential HealthCare HMO — Charlotte area 86100 BCT 4024-1 (as modified by GRP in 96605); 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.

RETURN TO HOMEPAGE