THE WELLNESS PLAN OF NORTH CAROLINA, INC.
Updated 10/2000

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

HMO General Information
Background Information	The Wellness Plan of North Carolina, Inc. (TWP-NC) received its HMO license to begin operations from the NC Department of Insurance on March, 18, 1996. It began operations on July 1, 1996. TWP-NC is a for-profit corporation, owned by the Charlotte Mecklenburg Hospital Authority.
Type of HMO	TWP-NC 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	TWP-NC’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. TWP-NC also offers a point-of-service option.
Accreditation	TWP-NC 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 TWP-NC is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Members	TWP-NC offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group" coverage) or Medicare recipients. TWP-NC does offer an HMO option to Medicaid recipients in Mecklenburg and Gaston counties.
Counties in which HMO has an Active Presence	TWP-NC has at least 25 commercial (group) HMO members at the end of 1999 in the following North Carolina counties: Alexander, Anson, Burke, Cabarrus, Caldwell, Catawba, Cleveland, Gaston, Iredell, Lincoln, Mecklenburg, Rowan, Rutherford, Stanly and Union.
Customer Service Number	1-800-794-9355
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: Unlimited days of care in a semiprivate room for medical surgical and obstetrical care, intensive and coronary care units. (Special duty nursing and private rooms when medically necessary). Room and board, general nursing care, and daily miscellaneous supplies. X-ray, laboratory, and other diagnostic tests. Operating rooms, intensive care unit, and coronary care unit. Pharmaceuticals, biologicals, fluids, and chemotherapy; anesthesia and oxygen services; whole blood, plasma, and other blood derivatives. Radiation and inhalation therapy. Physical therapy and special diets, when necessary. Up to 100 days per lifetime of short-term rehabilitation care. Limits: Prior approval required for non-emergency admissions.
Outpatient services		Covers: Outpatient surgery, diagnostic tests and therapy services.
Emergency care		Covers: Emergency services within medical service area. If members believe that an emergency exists, they should proceed to the nearest emergency care facility or dial 911 as appropriate. TWP-NC will pay for screening and treatment to stabilize your condition. You do not need prior authorization to seek emergency services. Emergencies outside service area: Follow the same procedure as you would within the service area. If possible, members should make every effort to obtain care in a participating hospital. TWP-NC will not pay for follow-up care rendered outside of the service area unless the member cannot return to the service area because of medical reasons. Notification requirements: After an emergency condition is stabilized, the member must notify TWP-NC of continued treatment. Notify your PCP as soon as reasonably possible, considering the member’s medical condition. A delay may result in denial of coverage for the services. Cost sharing: copayment applies, which will be waived if admitted to hospital.
Urgent Care		For non-emergent conditions, a member is required to contact his or her PCP or call the 24-hour nurse advice line to be directed to the appropriate medical facility for treatment and/or receive prior approval for urgent care facility services.
Ambulance		Covers: Ambulance in any emergency or when authorized by a TWP-NC physician.
Care for Students Outside of Service Area		Covers: Emergency care only.
Non-Urgent Care Outside of Service Area		Excluded.
Professional Services
Professional Services (general)		Covers: Routine primary care, physician office visits, referral to specialists, second medical opinions that are medically necessary, and inpatient physician services.
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		Covers: X-ray, lab, and other diagnostic tests.
Therapeutic Treatment Services		Covers: Radiation and chemo-therapy, and respiratory therapy for those patients who have undergone lung transplant, and when otherwise approved by the plan.
Allergy Testing and Treatment		Covers: Allergy injections and most testing, when provided by a participating physician board certified in allergy or specifically credentialed for allergy.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Periodic preventive examinations performed by the PCP for men, wome, and children. Excludes: Routine physical exams and testing required for marriage, or by third parties, such as schools, employers, athletic teams or judicial bodies, including court-ordered services except when medically necessary. Also excludes exams and vaccinations required to travel abroad.
Immunizations		Covers routine immunizations.
Preventive Clinical Services		Covers: Pap smears, mammograms, and PSA tests (as required in state law).
Other Health Promotion/Disease Prevention Activities		Covers: Vision and hearing screenings by the member’s PCP. Also covers nutrition counseling when approved.
Diabetic Treatment		Covers: Approved outpatient self-management training and education that is medically necessary.
Conception Services
Prenatal Care and Obstetrical Services		Covers: Prenatal and obstetrical services, including a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean sections. If the attending provider decides to discharge the mother and her newborn child before the expiration of the covered time, post delivery follow-up care is provided within 72 hours immediately following discharge. This follow-up care may be provided in the home, provider’s office, hospital, birthing center, or other appropriate setting.
Family Planning		Covers: Counseling, tubal ligation, vasectomy, diaphragms, IUDs, Norplant, and Depo-Provera. Excludes: Birth control, except for the treatment of a medical condition. Treatment must be prescribed by a physician and approved by TWP-NC. Note: Birth control pills may be covered under a supplemental policy.
Abortion		Excludes: Abortions, except where the life of the mother would be endangered if the fetus were carried to term, or under circumstances of rape or incest.
Infertility Services		Covers: Diagnosis of infertility and medically necessary artificial insemination for up to 3 attempts per lifetime. Limits: Artificial insemination is covered with the inability of a heterosexual couple to achieve conception after one year of unprotected sexual intercourse, or the inability of that couple to sustain a successful pregnancy. Excludes: Other infertility services and treatment.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Covers: Up to 28 days of inpatient mental health care per member. Care will only be covered if the condition is likely to improve with treatment within the specified benefit period. Limits: A behavioral health case manager picked by TWP-NC will manage the care. Services must be provided by participating providers. The member may obtain a referral for mental health services by his or her PCP or directly by calling the behavioral health case manager. Excludes: Treatments for chronic disorders, unless there is an acute episode. Excludes services for mental disorders or disabilities which can not be improved, according to generally accepted professional standards.
Mental Health Outpatient		Covers: Up to 20 outpatient visits per year for short-term crisis intervention, mental health evaluation and psychological testing, short-term individual and group psychotherapy, and psychotropic medication maintenance. Limits: A behavioral health case manager picked by TWP-NC will manage the care. Services must be provided by participating providers. The member may obtain a referral for mental health services by his or her PCP or directly by calling the behavioral health case manager
Substance Abuse Inpatient		Covers: Diagnosis and medical treatment. Limits: Inpatient and outpatient services are subject to a combined $8,000 calendar year maximum and a $16,000 lifetime maximum. A behavioral health case manager picked by TWP-NC will manage the care. Services must be provided by participating providers. The member may obtain a referral for mental health services by his or her PCP or directly by calling the behavioral health case manager.
Substance Abuse Outpatient		Covers: Diagnosis and medical treatment. Limits: Inpatient and outpatient services are subject to a $8,000 calendar year maximum and a $16,000 lifetime maximum. A behavioral health case manager picked by TWP-NC will manage the care. Services must be provided by participating providers. The member may obtain a referral for mental health services by his or her PCP or directly by calling the behavioral health case manager. Excludes: Hypnotic therapy for behavioral modification of smoking, obesity, etc.
Prescription Drugs and Medical Supplies
Prescription drugs		Covers: Prescription drugs, if medically necessary, prescribed by a licensed physician and dispensed at a participating pharmacy*. Also covers medications prescribed for treatment of emergent or urgent care conditions. Excludes: Non-prescription and experimental drugs. *with a prescription rider
Blood		Covers: Administration of blood for inpatient care. Also covers blood donated by a member before an elective procedure or surgery for use during the procedure ("autologous donation"). The process of separating blood into components ("apheresis"); and separation of the cellular elements from the plasma ("plasmapheresis") are covered services when approved by the plan. Excludes: Blood and blood products, unless available at no charge or through replacement.
Medical Supplies		Covers: Ostomy bags, diabetic, and other authorized supplies.
Insulin and Diabetic Supplies		Covers: Equipment, supplies, medication, lab services, outpatient self-management training and education. covered services must be medically necessary and appropriate.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)		Covers: Durable medical equipment, if medically necessary and provided through an approved provider. Motorized wheelchairs covered for quadriplegics only. Excludes: all other durable medical equipment, including batteries and hearing aids, loss, theft, and wear and tear before 24 months of use.
Prosthetic Devices		Covers: Internal prosthetics and initial external prosthetics. Limits: Replacement external prosthetics are covered when the old prosthesis no longer fits (for example, the person outgrows the appliance), and for normal wear and tear after 24 months of use.
Orthotic Devices		Covers: Orthotic devices, if medically necessary and appropriate. Excludes: Orthotics for routine foot care.
Rehabilitative and Habilitative Services
Physical therapy		Covers: Short-term restorative rehabilitation services for conditions that are expected to show significant improvement through short-term therapy, as determined by TWP-NC. Limits: Physical therapy limited to 20 sessions per illness or injury. Prior authorization is required.
Occupational therapy		Covers: Short-term restorative rehabilitation services for conditions that are expected to show significant improvement through short-term therapy, as determined by TWP-NC. Limits: Occupational therapy limited to 20 sessions per illness or injury. Prior authorization is required.
Speech Therapy		Covers: Short-term restorative rehabilitation services for conditions that are expected to show significant improvement through short-term therapy, as determined by TWP-NC. Limits: Speech therapy limited to 20 sessions per illness or injury. Prior authorization is required. Services are only covered when related to accident, disease, or medical condition. Excludes: Speech therapy except for treatment that is expected to restore speech to a person who has lost existing speech function as a result of accident, disease, or medical condition of member. Also excludes services for a dependent child when services are available.
Pulmonary Therapy		Excluded.
Chiropractic		Covered when medically necessary. Limits: Coverage limited to a maximum of $1500 per member per year.
Cardiac Rehabilitation		Covered when medically necessary and referred by a participating physician with prior approval.
Skilled Nursing Facility		Covers: Rehabilitative subacute and skilled nursing care. Limits: Limited to 100 days per lifetime when medically necessary.
Home-Based Services
Home Health		Covers: Visiting nurse services, nutrition services, and any drugs, medications, surgical dressings or related medical supplies administered during a home visit. These services will be covered in full if determined to be medically necessary by TWP-NC.
Private Duty Nursing		Excluded.
Hospice		Covers: Hospice for terminal conditions that is authorized by the member’s PCP. Limits: Hospice services are coordinated through TWP-NC‘s case management program. Hospice services are available once per lifetime.
Transplants and Dialysis
Transplants		Covers: All organ and tissue transplants. Limits: Transplants and all related charges are covered when approved in advance. Donor expenses: Covered when both the donor and the recipient are members of TWP-NC and the expenses are authorized in advance. Excludes: Any transplant considered or classified as experimental by FDA.
Dialysis		Covered.
Other Services
Dental		Covers: Medically necessary repairs as a result of accidental injury to sound and natural teeth. Medically necessary evaluation and treatment of TMJ due to congenital anomaly, disease, or accident. Surgery for oral tumors and cysts is also provided when medically necessary. Excludes: Routine dental or oral evaluation, treatment or surgery. Crowns, bridges, dentures, and extractions. Treatment of periodontal disease; dental root from implants. Root canals; orthodontic appliances. Treatment for teeth that are chipped or broken from biting or chewing.
Vision		Covers: Vision screening by PCP and routine exams once every 12 months by PCP or participating eye care provider. Excludes: Eye glasses, contact lenses, and other related appliances and supplies, unless purchased in a supplemental policy.
Hearing		Covers: Hearing screening by primary care provider. Excludes: Hearing aids and visits for fitting and post performance evaluation, unless covered by a supplemental policy.
Foot Care		Covers: Bone and tissue surgery for bunions and surgery for ingrown toenails. Routine foot care is covered for diabetic patients. Excludes: Foot care for routine nail cutting, corns, calluses, flat feet, fallen arches, weak feet or chronic foot strain. Also excludes supportive devices and manipulations of the foot.
Weight Loss		Excludes: All surgical procedures, services, and supplies for the purpose of weight control, weight management, and commercial weight loss reduction or gain programs.
Smoking Cessation		Excludes: Behavior modification programs and hypnotic therapy for smoking cessation. Also excludes prescription and non-prescription drugs for the purposes of smoking cessation.
Growth Hormones		Covered with prior approval.
Alternative Therapies		Excludes: Biofeedback therapy, acupuncture, and behavior modification programs (including hypnotherapy).
Reconstructive/Cosmetic Surgery		Covers: Reconstructive breast surgery and implants following mastectomy, including symmetry for non-diseased breast. Also covered when surgery will repair or correct normal functioning that was impaired by disease, trauma or congenital abnormalities, including cleft lip or cleft palate.
Non-Emergency Transportation		Excluded.
Excluded Services
Experimental or Investigational Services		Excluded.
Services that are not considered medically necessary		Excluded.
Non-emergency services rendered in the emergency room		Excluded.
Commonly excluded services		See list of commonly excluded services.
Definitions
Medically necessary		Definition of medically necessary follows statutory definition.
Experimental or Investigational		TWP-NC will decide that a service of supply is experimental or investigation if: The services or supplies requiring federal or other governmental approval do not have unrestricted market approval from the FDA or final approval from any other governmental regulatory body for use in treatment of a specific condition. There is insufficient or inconclusive evidence in peer reviewed medical journals to allow objective evaluation of the therapeutic value of the service or supply. There is inconclusive evidence that the service or supply has a beneficial effect on health outcomes. The service or supply has not proven to be as beneficial as other established alternatives. There is insufficient information or inconclusive scientific evidence that, when utilized in a non-investigational setting, the service or supply has a beneficial effect on health outcomes and is as beneficial as any established alternatives.
Emergency		Meets statutory definition of Emergency.
Urgent Care		A medical condition that occurs suddenly and unexpectedly, requiring prompt diagnosis and treatment, and that in the absence of immediate care the individual could reasonably be expected to suffer an extended illness, prolonged impairment, or require more intensive treatment. Examples include minor wounds, requiring stitches, possible urinary tract infections, and ear aches.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of providers who can serve as Primary Care Provider		PCPs can be in the specialties of Internal Medicine, Family Practice, Pediatrics and General Practice.
What Happens if Member Fails to Choose a PCP?		If you do not select a PCP, TWP-NC will notify the member that he or she needs to do so.
Process to Change PCP		You may change your PCP by written request or by calling member services.
Referrals to Specialists		The PCP must arrange referrals to participating specialists. TWP-NC will not pay for services provided by specialists (including participating and non-participating specialists) without approval by TWP-NC. Referrals are not needed for female health services of an OB/GYN.
Can Specialists Serve as PCP		No.
Non-Emergency Hospital Preauthorization requirements		You must obtain a referral from your PCP and prior approval of TWP-NC for non-emergency care.
Appeal and Grievance Procedures
Informal Reconsideration		TWP-NC will try to informally resolve members’ complaints. An informal, verbal complaint may be submitted in person or over the phone to any TWP-NC employee. TWP-NC will advise members of the right to file a grievance if the resolution is not to his or her complete satisfaction. TWP-NC tracks all informal complaints via an on-line system called AMISYS Phone Log.
First Level Non-Certification Appeal Provisions		Follows statutory definition. Note: Members or their representatives must submit first level appeal to TWP-NC. Members will receive written acknowledgement of the appeal within three business days and a written decision within 30 days of receiving relevant information.
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 submit first level grievance requests in writing to TWP-NC. No time limitations are specified in the Evidence of Coverage. Members will receive written acknowledgement of the grievance within three business days and a written decision within 30 days after receiving all relevant information.
Second-Level Grievance Hearings (covers second- level appeals and grievances)		Follows statutory definition. No time limitations are specified in the Membership Certificate for requesting Second-Level Grievance Hearings. Members will receive written acknowledgement of second level grievance within 10 business days. The second level review meeting will be held within 45 days of the PCP recieving a request for a second level grievance review. Member will be notified of the decision within seven 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 1-800-546-5664.
Notes		The grievance review process does not apply to grievances grounded solely on the basis that the plan does not cover the health care service in question.
Enrollment Trends
Enrollment on December 31, 1998 (Financial Report, # 10)		32,072
Member months (1998) (Financial Report, #11)		313,057
Average 1998 monthly enrollment (member months/12)		26,088
Percentage of change in average monthly enrollment between 1997-1998		3,561.5%
Five year average enrollment trends		1998: 26,088 1997: 8,215 1996: 713 1995: N/A 1994: N/A
Percentage of Groups that Disenrolled (December 31, 1997-December 31, 1998)		22%
Percentage of Members that Disenrolled (December 31, 1997-December 31, 1998)		7%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1997 — Dec. 31, 1998)		0%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1997 — Dec. 31, 1998)		0%
Utlization Review Information
Number of reviews requested, 1998		21,344
Review rate per 1,000 members, 1998		1,287
Percentage of noncertifications, 1998		8.32%
Noncertification rate per 1,000 members, 1998		106.99
Appeal Rate per 1,000 Noncertifications, 1998		29.29
Percentage of appeals decided for the members, 1998		86.54%
Financial Data
Total 1998 revenues (Financial Report, #6)		$43,212,605
Average premium per member per month (1998) (Financial Report, #5 / #11)		$121.33
Five year premium per member per month trends		1998: $121.33 1997: $107.81 1996: $98.21 1995: N/A 1994: N/A
Medical/hospital expenses per member per month 1998 (Financial Report, #7 / #11)		$118.12
Medical Loss Ratio 1998 (% premiums spent on medical/hospital expenses) (Financial Report, #15)		97.4%
Five year medical loss ratio trends		1998: 97.4% 1997: 86.5% 1996: 84.8% 1995: N/A 1994: N/A
Operating profit margin, 1998 (Financial Report, #9 / #6)		(4.6%)
Five year operating profit margin trends		1998: (4.6%) 1997: (16.7%) 1996: (128.5%) 1995: N/A 1994: N/A
Sources of Informationn
Source of Information		The Wellness Plan of North Carolina, Inc. of North Carolina, Inc., "Your Membership Certificate Booklet" MC100/0197; 1999 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 Utlization Review and Appeals and Grievances from NC Department of Insurance.

RETURN TO HOMEPAGE