WELLPATH SELECT
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	WellPath Select, Inc. received its HMO license from the NC Department of Insurance on October 26, 1995. It began operations on January 1, 1996. WellPath Select is a for-profit corporation, owned by Duke University and New York Life Insurance Company.
Type of HMO	WellPath 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	WellPath’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. WellPath also offers a point-of-service option, called "WellPath Select Plus."
Accreditation	WellPath 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 WellPath is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees	WellPath offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group" coverage) or Medicaid recipients. Will not offer Medicare HMO after 12/2000.
Counties in which HMO has an Active Presence	WellPath has at least 25 commercial (group) HMO members at the end of 1999 in the following North Carolina counties: Alamance, Burke, Cabarrus, Caldwell, Caswell, Catawba, Chatham, Cleveland, Cumberland, Davidson, Davie, Durham, Forsyth, Franklin, Gaston, Granville, Guilford, Harnett, Hoke, Iredell, Johnston, Lincoln, Mecklenburg, Montgomery, Nash, Orange, Person, Randolph, Rockingham, Rowan, Stanly, Stokes, Surry, Union, Vance, Wake, Warren, Wilson and Yadkin.
Customer Service Number	1-800-935-7284, 919-419-3868
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services	Covers: Semi-private room and board. Private room covered if medically necessary. Special diets and private duty nursing when medically necessary. Physician services. Operating room and related facilities. Anesthesia and oxygen services. Intensive care and other special care units and services. X-ray, laboratory and other diagnostic tests. Prescription medications and biologicals for use while an inpatient. Radiation and inhalation therapies. Visualizing dyes, intravenous (IV) preparations and chemotherapy. Cost Sharing: Copayment applies.
Outpatient services	Covers: Ambulatory surgery if provided by a participating provider, when referred by PCP and pre-approved by plan. Cost Sharing: Copayment applies.
Emergency care	Covers: Hospital emergency room services for screening, stabilization and treatment provided within and outside service area, at participating and non-participating facilities. emergency services are covered until the condition is stabilized. Nonparticipating facilities: Member must be transferred to the care for a participating provider as soon as this can be done without harming the member’s condition. Notice Request: The member (or someone acting for the member) should contact their PCP as soon as possible after seeking emergency care so that the PCP can coordinate follow up care for the member. Limits: Condition must require emergency care. Cost Sharing: Copayment applies, but will be waived if admitted to the hospital.
Urgent Care	Covers: Urgent care for medical services. In area urgent care: Member should first seek care through the PCP. If the PCP is unavailable, the member should seek care at a participating urgent care center. Out-of-area urgent care: Follows the same rules as for emergency care. Cost Sharing: Copayments apply.
Ambulance	Covers: Emergency ambulance service to the nearest medical facility. Also covers non-emergency ambulance transportation when pre-approved by WellPath.
Care for Students Outside of Service Area	Covered for Emergency and urgent care services only.
Non-Urgent Care Outside of Service Area	Excluded.
Professional Services
Professional Services (general)	Covers: Office visits, home visits and surgical procedures performed in the physician’s office. Also covers medications and materials administered or applied in physician’s office. Limits: Services must be provided by the member’s PCP or a participating provider on referral from PCP. Only covers home visits if member unable to leave home and services could not be performed by someone who is not a physician. Medications and materials are only covered if they could not be given in the member’s home by someone who is not a physician. Surgical procedures that involve anesthesia or is performed in a surgical suite must be approved in advance by the plan. Cost Sharing: Copayment applies.
OB/GYN	Covers: OB/GYN services for female members 13 years of age or older. referral not required for services of participating OB/GYN for care related to the female reproductive system. Cost Sharing: Copayment may apply.
Diagnostic Procedures	Covers: Inpatient and outpatient diagnostic procedures prescribed by participating physician. Includes lab and x-rays, radiology and radiation therapy. Cost Sharing: Additional copayment is not required if provided at participating physician or radiology facility.
Therapeutic Treatment Services	Covers: Radiation, Chemo-therapy, Respiratory Therapy
Allergy Testing	Covered.
Preventive Services
Annual Physicals (well-baby, well-child)	Covers: Well-baby and well-child care, routine sight, speech and hearing screenings for children, routine physicals for adults. Cost Sharing: Applicable office visit copayment applies.
Immunizations	Covers: Routine immunizations. Cost Sharing: Service included in the applicable office visit copayment. Excludes: Immunizations for travel outside the U.S., employment, school sports, extracurricular or recreation activities.
Preventive Clinical Services	Covers: Pap smears, mammograms, and PSA tests (as required in state law). Cost Sharing: No copayment if performed in a participating laboratory or radiological facility. Included in applicable office visit copayment if performed in participating physician’s office.
Other Health Promotion/Disease Prevention Activities	Covers: Certain health education and disease management services at HMO’s discretion.
Diabetic Treatment	Covers: medically necessary services, supplies, medications and laboratory procedures for the treatment of diabetes.
Conception Services
Prenatal Care and Obstetrical Services	Covers: Prenatal and other obstetrical services, including a minimum of 48 hours in the hospital after vaginal delivery or 96 hours after cesarean section. Cost-sharing: Copayment for the confirmation of pregnancy. For other visits to OB, there is no copayment. Excludes: Charges for the normal delivery of a baby outside of the member’s service area, if the delivery is within 30 days of the due date specified by the participating physician.
Family Planning	Covers: Physical exams, related laboratory tests and medical supervision provided by PCP. Information and counseling on contraception, including prescribing a contraceptive. Insertion and removal or an intrauterine device (IUD) or a birth control device implanted under the skin, such as Norplant. Fitting a diaphragm Vasectomy. Elective tubal ligation. Cost Sharing: Copayment applies. Excludes: Diaphragm unless covered separately under prescription drug supplemental policy.
Abortion	Covers: Elective abortions. Cost Sharing: Copayment applies.
Infertility Services	Covers: Diagnostic testing to determine the cause of infertility. Cost Sharing: Copayment applies. Excludes: Health services related to the treatment of infertility.
Mental Health and Substance Abuse Services
Mental Health Inpatient	Excluded unless covered by a supplemental policy. Most groups purchase the mental health inpatient rider. Covers with the purchase of a rider: Mental health inpatient services for evaluation of a recognized mental illness or disorder. Services must be provided by a hospital, residential facility, day care or day treatment program or other approved facility. Limits: Coverage limited to the equivalent of 30 inpatient days of covered treatment per calendar year. One day treatment (outpatient treatment) visit equals one-half day of inpatient treatment. The mental health services participating provider shall provide or arrange for the services. Services must reasonably be expected to significantly improve the member’s condition. Cost Sharing: Copayments apply. Excludes: Services for chronic psychosis, intractable personality disorders, mental retardation, mental deficiency, Alzheimer’s disease, chronic organic brain syndrome. However, acute episodes due to chronic brain syndrome will be covered. Chronic behavioral disorders if the member is not likely to improve significantly with short-term therapeutic management. Psychiatric therapy ordered by a court or administrative agency.
Mental Health Outpatient	Covers: Short-term services for evaluation or crisis intervention of a recognized mental illness or disorder. Limits: Limited to 20 treatment visits per calendar year. Only covered if the condition can reasonably be expected to improve significantly with short-term treatment. Services must be provided, arranged and managed by a participating mental health services provider. Cost Sharing: Copayment applies. Copayments made for mental health services do not apply toward copayment annual maximum.
Substance Abuse Inpatient	Excluded unless covered by a supplemental policy. Most groups purchase the chemical dependency rider. Covers, with the purchase of a supplemental policy: Inpatient hospital facilities, residential facilities for the treatment of chemical dependency. Limits: The participating provider of chemical dependency services must provide and arrange for the services. The covered services must be provided in the most cost-efficient setting that is appropriate for the member’s condition. Chemical dependency services are limited to an $8,000 annual maximum and a $16,000 lifetime maximum. Cost Sharing: Copayments apply.
Substance Abuse Outpatient	Excluded unless covered by a supplemental policy. Most groups purchase the chemical dependency rider. Covers, with the purchase of a supplemental policy: Residential facilities, social setting programs, day treatment, and other forms of outpatient care for the treatment of chemical dependency. Limits: The participating provider of chemical dependency services must provide and arrange for the provision of services. The covered services are provided in the most cost-efficient setting that is appropriate for the member’s condition. Chemical dependency services are limited to an $8,000 annual maximum and a $16,000 lifetime maximum. Cost Sharing: Copayments apply.
Prescription Drugs and Medical Supplies
Prescription drugs	Excludes outpatient drugs unless purchased under a supplemental policy. Covers under a supplemental policy: Prescription drugs, insulin and supplies for diabetes, nutritional formulas necessary for the treatment of phenylketonuria or other inherited disease. Limits: Drugs must be prescribed by a participating provider and purchased from a participating pharmacy. WellPath may limit quantity, dosage and mode of administration for some drugs. Some drugs must be approved in advance by WellPath or a pharmacy benefits manager. Members may obtain up to a 30-day supply of drug from any participating pharmacy, or a 90-day supply of a maintenance medication from certain participating pharmacies including participating mail order pharmacies. Cost Sharing: Copayments apply. There are higher copayments for brand name drugs than generics. Copayments are not counted towards either the annual prescription drug benefit limit or the annual maximum copayment limit. Out of area benefits: WellPath will reimburse the member for prescription drugs needed in out-of-area urgent care. Member must pay applicable copayment. Coverage is limited to a 10-day supply per prescription, unless the restriction imposes an undue hardship on the member. Excludes: Drugs intended for use in provider’s office or other clinical setting. Investigational or experimental drugs. Drugs for any work-related injury or illness if there is another source of coverage. Drugs prescribed for cosmetic purposes. Growth hormones except to treat a congenital anomaly. Weight reduction drugs. Allergy sera and allergy testing materials. Blood or urine testing devices except blood glucose testing for control of diabetes is covered. Contraceptive drugs and devices other than oral contraceptives and diaphragms. IUD, cervical caps and devices implanted under the skin, such as Norplant are excluded. Oxygen gas Any refill dispensed after the prescription has expired or more than 1 year after the date it was issued. Drugs prescribed for the treatment of infertility Off-label use drugs unless for cancer treatment. However, any drug which the FDA has determined to be contra-indicated for treatment of the specific type of cancer for which the drug has been prescribed is excluded.
Blood	Covers: Administration of blood. Excludes: The costs of whole blood, blood derivative and blood components, including any blood product, clotting factor, pooling agent or pooled product. Processing, storage and replacement costs are also excluded.
Medical Supplies	Covers: Insulin syringes, and disposable supplies required for diabetic testing with a blood glucose testing device (e.g. test strips, alcohol swabs and lancets) prescribed for a member to control his/her diabetes. Excludes: Disposable or consumable outpatient supplies, such as sheaths, bags, elastic garments and bandages, syringes, needles, blood or urine testing supplies, ostomy bags, home testing kits, oxygen, vitamins, dietary supplements and replacements, and special food items.
Insulin and Diabetic Supplies	Covers: Injectable insulin, insulin syringes, and disposable supplies required for diabetic testing with a blood glucose testing device (e.g. test strips, alcohol swabs and lancets) prescribed for a member to control his/her diabetes.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)	Excluded unless purchased separately through a supplemental policy. Most groups purchase the DME rider. Supplemental policy covers: The rental or purchase of standard durable medical equipment, such as non-motorized wheelchairs, crutches and canes, leg or back braces, traction equipment, oxygen equipment, or hospital beds. Limits: DME must be prescribed by a participating provider and approved in advance by WellPath. The decision to rent or purchase covered equipment is at the discretion of WellPath. Purchased equipment is the property of WellPath and must be returned to WellPath when the equipment is no longer medically necessary or the member’s coverage terminates under the plan. WellPath covers maintenance, repair and replacement unless due to member’s inappropriate use of such equipment. Excludes: Comfort or convenience items, bed boards, bath lifts, over-bed tables, air purifiers, exercise equipment, stethoscopes, and blood pressure gauges. The replacement of covered DME which is lost, misplaced or stolen is also excluded.
Prosthetic Devices	Covers: Internal, non-cosmetic prosthetic devices, including permanent aids and supports for defective body parts. Coverage includes joint replacements, cardiac pacemakers, permanent lenses following cataract surgery, and minor devices such as screw nails, sutures and wire mesh. Limits: Prosthetics must be prescribed by PCP and approved in advance by WellPath. Replacement limited to no more often than once every 12 months. Excludes: Artificial limbs, hearing aids, or durable medical equipment unless covered by a supplemental policy. Penile or testicular prostheses. Implantable insulin pumps or mechanical organ replacement devices such as artificial hearts or left ventricular assist devices. Splints and braces (unless they are used instead of casts). Supplemental policy: Covers purchase of external prosthetic devices that replace all or part of a defective body part. This includes artificial arms and legs, eyes and hands, hearing aids and breast prosthesis. Most groups purchase the prosthetic device rider.
Orthotic Devices	Excludes: Orthopedic shoes and other supportive device for the feet.
Rehabilitative and Habilitative Services
Physical therapy	Covers: Physical therapy if WellPath determines the condition is expected to significantly improve within 60 days. Also covers short-term inpatient therapy if the member is already receiving inpatient care and services can only be provided on an inpatient basis. Limits: Must be provided by a participating provider with prior approval from WellPath. Limited to maximum treatment period of 60 consecutive days per illness or injury. If services for the same condition are received on both an inpatient and outpatient basis, total coverage for both is limited to a maximum treatment period of 60 consecutive days. Cost Sharing: Copayment applies.
Occupational therapy	Covers: Occupational therapy if WellPath determines the condition is expected to significantly improve within 60 days. Also covers short-term inpatient therapy if the member is already receiving inpatient care and services can only be provided on an inpatient basis. Limits: Must be provided by a participating provider with prior approval from WellPath. Limited to maximum treatment period of 60 consecutive days per illness or injury. If services for the same condition are received on both an inpatient and outpatient basis, total coverage for both is limited to a maximum treatment period of 60 consecutive days. Cost Sharing: Copayment applies.
Speech Therapy	Covers: Speech therapy if WellPath determines the condition is expected to significantly improve within 60 days. Also covers short-term inpatient therapy if the member is already receiving inpatient care and services can only be provided on an inpatient basis. Limits: Must be provided by a participating provider with prior approval from WellPath. Limited to maximum treatment period of 60 consecutive days per illness or injury. Outpatient services are only provided to restore speech that was lost as a result of injury or disease. If services for the same condition are received on both an inpatient and outpatient basis, total coverage for both is limited to a maximum treatment period of 60 consecutive days. Cost Sharing: Copayment applies.
Pulmonary Therapy	Covers: Inhalation therapy administered in physician’s office or as part of inpatient care. Medically necessary pulmonary rehabilitation, subject to precertification by WellPath. Cost-sharing: Included in applicable office visit copayment. Excludes: Therapy that could be administered or applied at home or by someone who is not a physician.
Chiropractic	Covered with the purchase of a supplemental policy: Adjustment or manipulations of the spine for the detection or correction of body distortion caused by an acute condition or injury. Limits: must be provided by a participating provider with prior approval from WellPath. Limited to a maximum of 30 days per calendar year.
Cardiac Rehabilitation	Covers: Cardiac rehabilitation if WellPath determines the condition is expected to significantly improve within 60 days. Also covers short-term inpatient therapy if the member is already receiving inpatient care and services can only be provided on an inpatient basis. Limits: Must be provided by a participating provider with prior approval from WellPath. Limited to maximum treatment period of 60 consecutive days per illness or injury. If services for the same condition are received on both an inpatient and outpatient basis, total coverage for both is limited to a maximum treatment period of 60 consecutive days. Cost Sharing: Copayment applies.
Other Therapy Services	Covers: Pain management therapy if WellPath determines the condition is expected to significantly improve within 60 days. Also covers short-term inpatient therapy if the member is already receiving inpatient care and services can only be provided on an inpatient basis. Limits: Must be provided by a participating provider with prior approval from WellPath. Limited to maximum treatment period of 60 consecutive days per illness or injury. If services for the same condition are received on both an inpatient and outpatient basis, total coverage for both is limited to a maximum treatment period of 60 consecutive days. Cost Sharing: Copayment applies.
Skilled Nursing Facility	Covers: Semi-private room, meals and general nursing. Private room covered only if it is necessary due to infectious disease or immune problem and prior approval by WellPath. Limits: Must be admitted to a participating skilled nursing facility by a participating physician and approved in advance by WellPath. Limited to 100 consecutive days per illness or injury. Excludes: Custodial care or care for persistent illness and disorders.
Home-Based Services
Home Health	Covers: Home health care services. Limits: Services must be provided by a participating provider. Must have been referred by a participating provider and approved in advance by WellPath. There is no copayment for home health care. Cost Sharing: Copayment may apply for participating physician services at home. Excludes: Plan does not cover custodial care or care for persistent illness and disorders.
Private Duty Nursing	Covers: Special duty nursing services during inpatient admissions, only if prescribed by participating physician, and pre-approved by plan.
Hospice	Covers: Hospice services for terminally ill patients. The PCP must certify that the member has a life expectancy of six months or less and must prepare a written treatment plan authorizing services. Limits: Coverage is limited to a maximum period of 210 consecutive days, beginning with the first day member receives hospice care, whether at home, in a hospice or other inpatient facility. Coverage of bereavement counseling for family members is limited to a total of 5 visits per family.
Transplants and Dialysis
Transplants	Covers: Non-experimental transplants, including corneal, liver, kidney, kidney-pancreas, heart, lung, heart-lung, bone marrow and peripheral stem cell transplants. Limits: Covered if approved by a participating Center of Excellence and it is not experimental or investigational, as determined by WellPath. Cost Sharing: Copayments may apply. Excludes: Mechanical organ replacement devices, such as artificial hearts or left ventricular assist devices or any cross-species transplants. The plan does not cover any expenses relating to the donation of organs, tissues, bone marrow or peripheral stem cells unless the donor is also a member of a WellPath plan. Also, the plan does not cover any other donor expenses, including transportation costs.
Dialysis	Covers: Dialysis, subject to prior approval by WellPath and a referral by the member’s PCP.
Other Services
Dental	Covers: Treatment of a fractured or dislocated jaw or damage to sound natural teeth caused by accidental injury. Limited coverage for removing cysts of the mouth. Diagnosis and treatment of TMJ or TMC by splinting, the use of intraoral prosthetic appliances to reposition the bones or surgery. Limits: Treatment for injury must be sought within 72 hours of the accidental injury. Treatment of a fractured or dislocated jaw or damage to teeth will not last beyond 365 days. Treatment of TMJ only covered to treat a condition which prevents normal functioning of the bone or joint. The bone or joint abnormality must be caused by disease, injury or congenital deformity. There is a $3,500 lifetime maximum on WellPath coverage of nonsurgical treatment of the TMJ. Services must be provided by a participating provider with prior approval of WellPath. Cost Sharing: Copayments may apply. Excludes: Routine dental work. X-rays or exams. Crowns, bridges or dentures. Dental prostheses or cosmetic surgery for shortening or lengthening the jaw. Orthodontics. Extracting teeth. Treatment for periodontal disease. Dental root form implants or root canals. Removal of cysts directly related to the teeth and their supporting structures.
Vision	Covers: Routine screenings for members through age 17, when performed by PCP. Also covers eye tests when medically necessary due to a sickness or injury. WellPath will pay for the first pair of eyeglasses or non-disposable contact lenses prescribed as a result of cataract surgery. Cost-sharing: Copayment may apply. Excludes: Eye exams to prescribe glasses or contact lenses; vision therapy unless purchased separately as a supplemental policy. Also excludes eyeglasses, contact lenses or their fitting, any other items or services for the correction of eyesight, orthoptics, vision training, and radial keratotomy or similar surgery for the treatment of myopia and keratoplasty. Supplemental policy covers: One vision examination every 24 months by a participating optometrist, including refraction and glaucoma screening. Referral from PCP not required.
Hearing	Covers: Routine screenings through age 17, when performed by PCP. Cost-sharing: Copayment may apply. Exclusions: Hearing testing and therapy. Also excludes hearing aids and other appliances for the correction of hearing deficiencies.
Foot Care	Covers: Non-routine foot care. Excludes: Routine foot care, including treatment of flat feet, corns, bunions, calluses, and ingrown toenails. Also excludes arch supports and other foot support devices, elastic stockings, corrective orthopedic shoes, orthotic shoe inserts, braces, splints or other foot care items.
Weight Loss	Excludes: Services intended primarily for weight reduction, such as diet programs, gastric bypasses and balloons, stomach stapling and jaw wiring. Also excludes nutritional counseling and diet planning unless approved in advance by WellPath.
Smoking Cessation	Covers: Over-the-counter and prescription treatments of smoking cessation up to $165 per lifetime. Supplemental rider covers: Reimbursements up to $165 per lifetime for over-the-counter and prescription smoking cessation treatments. Most groups purchase the supplemental rider.
Growth Hormones	Excluded, unless purchased separately under supplemental policy.
Alternative Therapies	Excluded from base policy but offers: Stress management, massage therapy, acupuncture, discounts on vitamins, herbs and other alternative therapies and treatments. Members receive a 20% discount off participating health care providers’ charges and at least a 10% discount at participating retail stores.
Reconstructive/Cosmetic Surgery	Covers: Reconstructive breast surgery following mastectomy. Also covers reconstructive surgery if needed to repair damage from an accidental injury, remove a tumor occurring while a member of WellPath, or to correct a birth defect or an anomaly in a bodily function of a dependent child covered by the plan. Cost Sharing: Copayments may apply. Excludes: Treatment that is primarily intended to improve the member’s physical appearance, whether for emotional, psychological or any other reasons.
Non-Emergency Transportation	Excluded, except when member has received prior approval of WellPath.
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	Follows statutory definition of medical necessity.
Experimental or Investigational	A drug, device, treatment or procedure is experimental or investigational if: It cannot be lawfully marketed without the approval of the FDA and approval has not been given at the time it is provided. Subject to federal law requiring Institutional Review Board review and approval for proposed use. The subject of ongoing Phase I, II or III clinical trials is otherwise under study to determine its maximum tolerated dose, toxicity, safety, effectiveness, or its effectiveness compared to a standard method of treatment or diagnosis. Reliable evidence shows that the prevailing opinion among experts is that further studies or clinical trials of the drug, device, treatment or procedure are needed.
Emergency	Follows statutory definition.
Urgent Care	"Out-of-area Urgent care" means care that is not emergency care, but: Is needed urgently by a member while he/she is outside the service area. This need could not reasonably have been anticipated before the member left the service area. Cannot safely be postponed until the member is able to return to the service area to obtain care through his/her PCP.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of providers who can serve as Primary Care Provider	General practitioner, family practitioner, internist or pediatrician. A nurse practitioner or physician who meets plan criteria may also be chosen as a PCP.
What Happens if Member Fails to Choose a PCP?	If the member does not select a PCP, he or she will not be able to receive coverage for services except for emergency care and out-of-area care. Members who fail to choose a PCP may obtain the following services: emergency care out-of-area care covered gynecological services from a participating OB/GYN covered obstetrical services, including regular prenatal care from a participating obstetrician services provided under riders that do not require PCP's referral.
Process to Change PCP	Member should notify WellPath of intent to change PCP either in writing or by calling member services prior to receiving care from the new PCP.
Referrals to Specialists	Referrals to participating specialists: PCP must evaluate member’s condition and provide member with a referral form before service is provided. Referrals to non-participating specialists: Care obtained from non-participating providers will be covered only if: Care is provided as a part of covered emergency or out-of-are urgent care. Covered services cannot be provided by a health care provider in the network without unreasonable delay, the PCP provides a referral, and WellPath pre-approves the referral.
Can Specialists Serve as PCP	No.
Non-Emergency Hospital preauthorization requirements	Participating hospitals: Requires pre-approval by WellPath for all admissions. The only exception is for emergency admissions covered under emergency and out-of-area urgent care provisions. Non-participating hospitals: Not listed in Evidence of Coverage.
Appeal and Grievance Procedures
Informal Reconsideration	Requesting informal reconsideration: The member may contact WellPath Member Services representative by telephone or in person at WellPath’s administrative office to file an informal complaint about access or quality of care or payment of claims. A member can also request an informal reconsideration of a service denial. Review process: Informal reconsideration of service denials is between the provider involved, and a doctor designed by WellPath. A representative of WellPath and a doctor designated by WellPath will investigate other complaints. Decision notification: A decision of the informal review of the denied services will be given within 3 business days of requesting a review. All other informal complaints will be investigated and a decision made within 30 days.
First Level Non-Certification Appeal Provisions	Follows statutory definition. Note: Members or their representatives must submit first level appeal to WellPath within 60 days their informal reconsideration, UM or claims decision. Members will receive a response from WellPath within 30 days of WellPath’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 submit written requests for grievance review. No time limitations are specified in the Evidence of Coverage. Members will receive a response within 30 days of the receipt of the grievance.
Second-Level Grievance Hearings (covers second- level appeals and grievances)	Follows statutory definition. Note: Requests for second level grievance hearings must be made in writing to WellPath within 30 days following a first level appeal or grievance decision. The second level review meeting will be held within 45 days of receipt of 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 NC Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes	Limitations of Informal and Formal Appeal and Grievance Process: The appeal and grievance process does not apply to denials rendered solely on the basis that WellPath 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, 1999 (Financial Report, # 10)	113,223
Member months (1999) (Financial Report, #11)	1,332,155
Average 1999 monthly enrollment (member months/12)	111,013
Percentage of change in average monthly enrollment between 1998-1999	109%
Five year average enrollment trends	1999: 111,013 1998: 53,189 1997: 15,192 1996: 2,136 1995: N/A
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)	18%
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)	17%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)	10%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998— Dec. 31, 1999)	0%
Utilization Review Information
Number of reviews requested, 1999	26,739
Review rate per 1,000 members, 1999	530
Percentage of noncertifications, 1999	2.11%
Noncertification rate per 1,000 members, 1998	11.18
Appeal Rate per 1,000 Noncertifications, 1999	115.25
Percentage of appeals decided for the members, 1999	26.47%
Financial Data
Total 1999 revenues (Financial Report, #6)	$186,598,066
Average premium per member per month (1999) (Financial Report, #5 / #11)	$139.15
Five year premium per member per month trends	1999: $139.15 1998: $127.43 1997: $117.66 1996: $113.96 1995: N/A
Medical/hospital expenses per member per month 1999 (Financial Report, #7 / #11)	$128.51
Medical Loss Ratio 1999 (% premiums spent on medical/hospital expenses) (Financial Report, #15)	98.0%
Five year medical loss ratio trends	1999: 98.0% 1998: 100.8% 1997: 88.8% 1996: 84.9% 1995: N/A
Operating profit margin (Financial Report, #9 / #6)	(7.0%)
Five year operating profit margin trends	1999: (7.0%) 1998: (15.0%) 1997: 1.0% 1996: 7.0% 1995: N/A
Sources of Information
Source of Information	WellPath Inc., Group Service Agreement Certificate of Coverage, NC-GSA-HMO-0396; 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on Utilization Review and Appeals and Grievances from NC DOI.

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