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2006 New JerseyHMOPERFORMANCEREPORTCompare Your ChoicesJon S. CorzineGovernorSteven M. GoldmanCommissioner
The New Jersey Department of Health and SeniorSeptember 2006Dear Consumers:We are pleased to present the tenth annualNew Jersey HMO Performance Report, the firstproduced exclusively by the New JerseyDepartment of Banking and Insurance. Thisreport contains information on the performanceof New Jersey’s health maintenanceorganizations (HMOs), how well these HMOsdeliver important health care services, and howmembers rate the services they receive.The report is designed to give consumers andemployers information on the quality of NewJersey’s HMOs and the coverage they provide.We believe that you will find this informationuseful when choosing health coverage for yourfamily or business.New Jersey is a leader in providingcomprehensive, strong consumer and patientprotections. We urge you to become familiar withthese protections, which are explained in thisreport.By providing you with this report, we strive toempower you to make the best health carechoices for you, your family or your employees.Jon S. CorzineGovernorSteven M. GoldmanCommissionerDepartment of Banking and InsuranceServices (DHSS) developed the format for this report withthe cooperation of the New Jersey HMOs. DHSS wasguided by an advisory group representing health plans,health care purchasers, providers and consumers. TheNew Jersey Department of Banking and Insurance (DOBI)assumed responsibility for providing the HMO PerformanceReport from DHSS in August 2005, pursuant toReorganization Plan 05-005. All regulatory and oversightmatters concerning managed health care in the state arenow consolidated in DOBI.This report includes information on all commercial productscurrently marketed in New Jersey by HMOs that had atleast 2,000 members enrolled in commercial products inboth 2004 and 2005. For most HMOs the informationcombines plan performance for the HMO and POSproducts. See page 20 for more information about thedistinction between HMO and POS products.This report does not cover the performance of HMOs thatserve Medicare beneficiaries or beneficiaries of Medicaidand other New Jersey Department of Human Servicesprograms. See page 19 for ways you can obtaininformation on these plans.This report is based on a measurement system calledHEDIS , which was developed by the National Committeefor Quality Assurance (NCQA) through the combinedefforts of many health care experts. It includes measurescollected by the HMOs and measures collected throughmember surveys. All measures are verified by independentauditors.This report contains information on the following HMOs andproducts: Aetna-HMO/POS (Aetna Health, Inc.–New Jersey) AmeriHealth-HMO/POS (AmeriHealth HMO) CIGNA-HMO/POS (CIGNA HealthCare of New Jersey) Health Net-HMO/POS (Health Net of New Jersey, Inc.) Horizon-HMO (Horizon Healthcare of New Jersey) Oxford-HMO/POS (Oxford Health Plans–New Jersey) United-HMO/POS (UnitedHealthcare of New Jersey, Inc.) WellChoice-HMO (WellChoice HMO of New Jersey)**WellChoice is also known as Empire HealthChoice.For information on contacting these and otherNew Jersey HMOs, see page 16.TThis report is also available on the Department’seweb site:Department’sweb al/2006hmoperformancereport.pdfData analysis was provided by the Center for State Health Policy, Rutgers, the StateUniversity of New Jersey.HEDIS is a registered trademark of the National Committee for Quality Assurance.
New Jersey HMO Performance ReportContentsQuality Matters .2Performance Summary .3Service and Access .4-5How HMO members rated their: HMO overall ability to get needed care HMO’s claims processing HMO’s customer serviceDoctors and Medical Care . .6-7How HMO members rated: the quality of care they received how quickly they got care their personal doctor their doctor’s ability to communicate wellStaying Healthy . .8-9How well HMOs made sure that: women received a mammogram (a test for breast cancer) women received a Pap test (a test for cervical cancer) new mothers had a check-up after delivery children received recommended immunizationsGetting Better/Living with Illness .10-13How well HMOs made sure that the members: being treated with medicine for depression were monitored appropriately with mental illness saw a provider after hospitalization with pediatric asthma received appropriate medications with hypertension had their blood pressure controlled with heart conditions had their cholesterol controlled who had a heart attack received appropriate medicine with diabetes had their blood sugar tested with diabetes, who are at risk for blindness, received an eye examChoosing Your HMO . 14Taking Responsibility for Your Health Care . 15Contacting Your HMO .16-17Appeals and Complaints .18Other Important Resources . .19HMO and POS Differences . . .20Consumer Bill of Rights . .Inside Back Cover2006 New Jersey HMO Performance Report1
Quality MattersImportant Questions About Quality You Should ConsiderWhat do you know about the quality of New Jersey HMOs?This report provides information about how: members rated their HMOs and doctors easily members got the care they needed well HMOs provided preventive care, such as immunizations and mammograms, to help membersstay healthy well HMOs cared for members who are ill, such as managing the cholesterol level of people withheart conditionsWhy is the quality of health care important?Not all HMOs are the same. HMOs differ in how well they keep members healthy and care for them when theybecome sick. That’s why learning about health care quality is important. If you are a consumer, the quality of care provided by your HMO may influence your health andyour family’s health. If you are an employer, the quality of care provided by your HMO may influence absenteeism,employee productivity and your company’s health care costs.What should you consider when choosing your HMO?You can use this report, along with cost and benefit information available from your employeror the HMO, to choose the best HMO for you.When choosing an HMO, consider: Whether your doctor or health care provider is available in the HMO’s network Whether the HMO offers the benefits you want How much the HMO will cost you (look at both monthly premiums and out-of-pocket expenses, such asco-payments, coinsurance and deductibles) How well the HMO performs in areas most important to youLook at Quality—See the next page for HMO performance22006 New Jersey HMO Performance Report
Performance SummaryHow New Jersey HMOs Perform OverallThis chart summarizes New Jersey HMO performance in four broad areas by comparing each HMO’sperformance to the statewide HMO average. Each broad area is made up of several performance measures,which are further described on the following pages.Higher than average scores mean better performance. Performance Comparedto the AverageHigher than the New Jersey HMO averageAbout the Same as the New Jersey HMO averageLower than the New Jersey HMO averageOverall Performancesee the following pages for more detailService andAccessDoctors andMedical CareStayingHealthyGettingBetter/Livingwith IllnessSee pages 4 & 5See pages 6 & 7See pages 8 & 9See pages 10-13Aetna - HMO/POS AmeriHealth - HMO/POS CIGNA - HMO/POS Health Net - HMO/POS Horizon - HMO Oxford - HMO/POS United - HMO/POS WellChoice - HMO HMO2006 New Jersey HMO Performance Report3
Service and AccessAre members satisfied with their HMO’s services?A comparison of each HMO’s performance to the New Jersey HMO average shows how effective the HMOsare in providing services to their members (pages 4 and 5).Higher than average scores mean better performance.Rating ofHMOGetting HMO/POS AmeriHealth - HMO/POS CIGNA—HMO/POS Health Net—HMO/POS Horizon—HMO Oxford—HMO/POS United—HMO/POS WellChoice—HMO HMODue to differences in sample size, HMOs with the same or similar scores can have different circle ratings.Performance Compared to the Average Higher than the New Jersey HMO averageAbout the Same as the New Jersey HMO averageLower than the New Jersey HMO averageSee the next page for each HMO’s scores Æ42006 New Jersey HMO Performance Report
Rating of HMOGetting needed carePercent of members who rated their HMOa 9 or 10 on a scale from 0 (worst possible) to 10(best possible):Percent of members who reported no problemgetting a personal doctor they like to see aspecialist necessary tests or treatment timelyapprovals for care:NJ AverageNJ alth81%CIGNA31%CIGNA38%Health Net33%Horizon39%Oxford33%WellChoice34%20%Health hoice40%60%69%0%80% 100%20%40%60%80% 100%Customer serviceClaims processingPercent of members who said their HMO alwayshandled their claims in a reasonable amountof time correctly:NJ Average47%57%AetnaPercent of members who reported no problem finding or understanding written information getting needed help from customer service completing paperwork:NJ A45%CIGNA66%Health Net44%Health oice70%Oxford53%43%United45%WellChoice0%20%40%60% 80% 100%0%20%40%60%80% 100%2006 New Jersey HMO Performance Report5
Doctors and Medical CareAre HMO members satisfied with their doctors and medical care?A comparison of each HMO’s performance to the New Jersey HMO average shows how effective the HMOsare in providing high quality medical care to their members (pages 6 and 7).Higher than average scores mean better performance.Rating ofhealth careGetting carequicklyRating ofpersonaldoctorHow welldoctorscommunicateAetna—HMO/POS AmeriHealth - HMO/POS CIGNA—HMO/POS Health Net—HMO/POS Horizon—HMO Oxford—HMO/POS United—HMO/POS WellChoice—HMO HMODue to differences in sample size, HMOs with the same or similar scores can have different circle ratings.Performance Compared to the Average Higher than the New Jersey HMO averageAbout the Same as the New Jersey HMO averageLower than the New Jersey HMO averageSee the next page for each HMO’s scores Æ62006 New Jersey HMO Performance Report
Rating of health careGetting care quicklyPercent of members who rated their quality of carea 9 or 10 on a scale from 0 (worst possible) to 10(best possible):Percent of members who said they always were ableto obtain advice, get timely appointments and getcare for an illness or injury never had to wait over15 minutes past appointment time to see a provider:NJ Average49%Aetna53%NJ A49%CIGNA40%Health Net47%Health 46%WellChoiceUnited50%0%20%40%43%WellChoice60%80% 100%40%0%20%40% 60%80% 100%Rating of personal doctorHow well doctors communicatePercent of members who rated their personaldoctor a 9 or 10 on a scale from 0 (worst possible)to 10 (best possible):Percent of members who said their doctor always listened carefully explained things clearly showed respect spent enough time with them:NJ AverageNJ h58%CIGNA49%CIGNA56%60%Health Net63%57%Oxford56%OxfordHealth oice50%WellChoice60%0%20%40%60%80% 100%0%20%40%60%80% 100%CTORS AND MEDICAL CARE2006 New Jersey HMO Performance Report7
Staying HealthyHEALTH PLAN Testing forDoes the HMO help members stay healthy and avoid illness?A comparison of each HMO’s performance to the New Jersey HMO average shows how effective the HMOsare in working with doctors to provide important preventive services that help members stay healthy (pages 8and 9).Higher than average scores mean better performance.Testing forbreast cancerTesting forcervical cancerCheck-ups fornew mothersImmunizationsfor childrenAetna—HMO/POS AmeriHealth - HMO/POS CIGNA—HMO/POS Health Net—HMO/POS Horizon—HMO Oxford—HMO/POS United—HMO/POS WellChoice—HMO HMODue to differences in sample size, HMOs with the same or similar scores can have different circle ratings.Performance Compared to the Average Higher than the New Jersey HMO averageAbout the Same as the New Jersey HMO averageLower than the New Jersey HMO averageSee the next page for each HMO’s scores Æ82006 New Jersey HMO Performance Report
Testing for breast cancerTesting for cervical cancerWomen are more likely to survive if breast cancer isfound early through a mammogram (x-ray of thebreast). Percent of women aged 52–69 whoreceived a mammogram within the past two years:Women are more likely to survive if cervical canceris found early through a Pap test. Percent of womenaged 18–64 who received a Pap test within the pastthree years:66%NJ AverageNJ h Net81%AmeriHealth65%CIGNA78%78%Health ted77%WellChoice77%61%WellChoice0%20%40%60%80% 100%During a visit, providers can check a new mother’srecovery from childbirth and answer questions.Percent of new mothers who received a check-upwithin eight weeks after delivery:79%78%Aetna84%AmeriHealth0%80% 100%83%Health 68%UnitedWellChoice69%WellChoice80% 100%75%AmeriHealthHealth Net40% 60%60%AetnaCIGNA20%40%NJ Average84%0%20%Immunization shots prevent childhood diseasessuch as polio, measles, mumps, rubella andwhooping cough. Percent of children who receivedrecommended immunizations by age two:CIGNAOxford80%Immunizations for childrenCheck-ups for new mothersNJ Average77%73%61%74%0%20%40% 60%80% 100%2006 New Jersey HMO Performance Report9
Getting Better/Living with IllnessHow well does the HMO care for members who are sick?A comparison of each HMO’s performance to the New Jersey HMO average shows how effective the HMOsare in working with doctors to care for members who are sick or living with chronic illness (pages 10–13).Higher than average scores mean better performance.Management ofmedicine fordepressionCare afterhospitalizationfor mentalillnessAppropriatemedicationsfor asthma(children)Controllinghigh bloodpressureAetna—HMO/POS AmeriHealth - HMO/POS CIGNA—HMO/POS Health Net—HMO/POS Horizon—HMO Oxford—HMO/POS United—HMO/POS WellChoice—HMONot ApplicableNot ApplicableNot Applicable HMODue to differences in sample size, HMOs with the same or similar scores can have different circle ratings.Not Applicable—HMO was unable to report the measure due to the small number of eligible members.Performance Compared to the Average Higher than the New Jersey HMO averageAbout the Same as the New Jersey HMO averageLower than the New Jersey HMO averageSee the next page for each HMO’s scores Æ102006 New Jersey HMO Performance Report
Management of medicinefor depressionCare after hospitalizationfor mental illnessPeople taking medicine for depression need to bemonitored. Percent of members given medicine fordepression who had follow-up visits:Therapy after a hospital stay for mental illness isimportant for recovery. Percent of membershospitalized for mental illness who received careafterwards:NJ AverageNJ Average30%Aetna28%Health Net39%Horizon29%United24%WellChoice20%80%Health Net81%86%Oxford72%United73%Not ApplicableWellChoiceNot CIGNA79%Aetna25%AmeriHealth78%40% 60%With appropriate therapies, long term control ofpersistent asthma can be achieved, resulting in adecrease in hospitalizations and emergency roomvisits for treatment. Percent of pediatric membersaged 5–17 with persistent asthma who received anappropriate therapy in the past year:94%92%Aetna95%AmeriHealth20%40% 60%80% 100%Controlling high blood pressureAppropriate medicationsfor asthma (children)NJ Average0%80% 100%High blood pressure (hypertension) is a majorrisk factor for a number of diseases and must beclosely monitored and controlled. Percent ofmembers aged 46–85 with hypertension whoseblood pressure was under control at their mostrecent medical visit:NJ alth Net97%Health 96%UnitedWellChoiceNot Applicable0%20%40%61%WellChoice60%80% 100%70%0%20%40%60%80% 100%2006 New Jersey HMO Performance Report11
Getting Better/Living with Illness (continued)How well does the HMO care for members who are sick?A comparison of each HMO’s performance to the New Jersey HMO average shows how effectivethe HMOs are in working with doctors to care for members who are sick or living with chronic illness(pages 10–13).Higher than average scores mean better performance.Cholesterolmanagement ofheart patientsBeta blockertreatment aftera heart attackBlood sugartesting forpeople withdiabetesEye exams forpeople withdiabetesAetna—HMO/POS AmeriHealth - HMO/POS CIGNA—HMO/POS Health Net—HMO/POS Horizon—HMO Oxford—HMO/POS United—HMO/POS WellChoice—HMO Not Applicable HMODue to differences in sample size, HMOs with the same or similar scores can have different circle ratings.Not Applicable—HMO was unable to report the measure due to the small number of eligible members.Performance Compared to the Average Higher than the New Jersey HMO averageAbout the Same as the New Jersey HMO averageLower than the New Jersey HMO averageSee the next page for each HMO’s scores Æ122006 New Jersey HMO Performance Report
Cholesterol managementof heart patientsBeta blocker treatment aftera heart attackReducing cholesterol lowers the chances of having aheart attack. Percent of members with heart conditionswho had their cholesterol level controlled:Beta blockers after a heart attack can help preventfuture heart attacks. Percent of members who had aheart attack and received beta blockers:NJ AverageNJ riHealthCIGNA67%CIGNAHealth Net67%Health ited0%20%40% 60%80% 100%84%84%83%AmeriHealth0%20%40%60%80% 100%Eye exams for people with diabetesControlling blood sugar levels can preventcomplications from diabetes. Percent of members withdiabetes who had a blood sugar (HbA1C) test:AetnaNot ApplicableWellChoiceBlood sugar testing for peoplewith diabetesNJ Average98%United73%WellChoice99%Regular eye exams can reduce the risk of blindnessfrom diabetes. Percent of members with diabeteswho received an eye exam:NJ alth Net84%Health 81%UnitedWellChoice82%WellChoice0%20%40%60%80% 100%63%43%0%20%40%60%80% 100%2006 New Jersey HMO Performance Report13
Choosing Your HMOYour choice of an HMO can influence your health.Looking at HMO quality, along withchoice of providers, benefits offered,and costs, can help you decide on anHMO that best meets your needs.Quality of Care and Service Look to see how well the HMO performs in eachsection of this report.Cost Try to get an idea of how much you are likely topay in premiums, co-payments, coinsurance anddeductibles each year. Find out if the HMO covers services by providersoutside the HMO’s network and how much it willcost for these services. Pay special attention to the health issues that aremost important to you and your family. See if there are any limits on how much you areresponsible for paying in case of major illness(out-of-pocket maximum). Do not focus on small differences in a singlemeasure that may not be meaningful. To compareHMOs, look at all the factors that contribute to anHMO’s performance and at large differences inthe measures. The HMO might also have internal limits onspecific services, such as dollar, day or visitlimits for specific services. Find out if the HMO places limits on the amount ofbenefits it will pay (annual or lifetime maximums).Choice of Providers Make sure that your preferred doctor, hospital andother providers participate in the HMO’s networkby looking in the HMO’s provider directory. It isimportant to confirm your provider’s participationby calling the HMO’s member servicesdepartment or the provider directly, prior toenrollment. See page 16 for ways to contact theHMO. Decide whether the HMO has enough of the kindsof doctors you are likely to need and whether theyare located near your home or work. Once you have selected a provider, make surethe doctor has office hours and a locationconvenient for you and your family.Benefits Find out what types of health benefit plans theHMO offers by reviewing the member handbook orcalling the member services department. Consider your special needs and circumstancessuch as chronic health conditions, elder care,frequent travel, language, retirement and startinga family. Decide whether there is a good match betweenthe health benefits offered by the HMO and whatyou think you may need. Find out what types of care or services the HMOdoes not cover.142006 New Jersey HMO Performance ReportAccreditationNCQA, also known as the National Committeefor Quality Assurance, is a non-profitorganization committed to assessing, reportingon and improving the quality of care provided bythe nation’s carriers offering managed carehealth benefits plans. To find out if your carrieris NCQA accredited, call toll-free (888) 2757585 or visit the web site: www.ncqa.org.URAC, also known as the AmericanAccreditation HealthCare Commission is a nonprofit organization originally focused on theaccreditation of utilization review programs.URAC now provides accreditation services formany types of health care organizations,including HMOs. For information on URAC’saccreditation services, visit the web site:www.urac.org.JCAHO, also known as the Joint Commissionon Accreditation of Healthcare Organizations, isan independent, non-profit organization thatevaluates and accredits various types of healthcare networks including health carriers,hospitals, home health care organizations andothers. For more information on JCAHO'saccreditation services, visit the web site:www.jcaho.org
Taking Responsibility for Your Health CareGetting involved in your health care can help youget the most from your health coverage.Know the Rules Understand what services your healthbenefits plan does and does not cover byreading the member handbook or talkingto your employer. Know how to choose or change your primarycare physician. Understand how to schedule appointments forcheck-ups and when you are sick. Know when you need referrals orpreauthorization for a procedure and how toget them. Know what you are required to do when usinga hospital or emergency room. Set up health files to keep track of the careand services received by you and members ofyour family.Take Charge Take good care of your health by makingappointments for check-ups and preventivecare. Talk with your doctor about when you needregular health screenings. Call member services if you don’t understandinformation that the HMO or provider sendsyou. Ask for a better explanation if you don’tunderstand the answers to your questions.Stay Informed Learn about any new policies affecting howthe HMO and your health benefits plan worksby reading member newsletters and checkingthe HMO’s web site. Know the telephone numbers and hours ofyour physician’s office and of the HMO’smember services department. Carry them inyour wallet or purse in case of emergency.Keep Records Write down your health concerns to help youdiscuss them with your doctor.Choose a Doctor Carefully Ask for recommendations from medicalsocieties, health care providers, referralservices, hospitals, family members andfriends. Get information about the doctor’s training andexperience from the HMO or the doctor. Ask if the doctor is board certified in his or herspecialty area. Check whether prospective doctors have hadany disciplinary actions issued against them.For information on New Jersey physicians seepage 192006 New Jersey HMO Performance Report15
Contacting Your HMOThe information in this report covers the HMOs offering commercial HMO and POS products in New Jersey.This chart lists all active HMOs approved to issue HMO and POS products in New Jersey. The chart shows ifthe HMO offers commercial coverage and if it participates in Medicare or Medicaid. It also shows the countiesthat each HMO is authorized to serve. An HMO may not offer Medicare or Medicaid in all the counties in itsservice area. Look at the chart notes to find the counties where an HMO participates in Medicare or Medicaid.NOTES:1. Aetna Medicare isavailable in Bergen,Essex, Hudson, Morris,Passaic, Sussex andUnion (North); Mercer(Center); and Burlington,Camden, Gloucester andOcean (South).Telephone Numbers, Web SitesHMOTelephoneWeb siteAetna Health, Inc.—New Jersey(800) 872-3862www.aetna.comAmeriChoice of New Jersey(800) 941-4647www.americhoice.comAMERIGROUP New Jersey(800) 600-4441www.amerigroupcorp.comAmeriHealth HMO(866) 681-7368www.amerihealth.comCIGNA HealthCare of New Jersey(800) 345-9458www.cigna.com/health5. Health Net Medicaid isavailable in Essex,Hudson, Passaic andUnion (North); Mercer,Middlesex andSomerset (Center); andBurlington, Camden,Cumberland, Gloucester,Ocean and Salem(South).Health Net of New Jersey, Inc.(800) 441-5741www.healthnet.comHorizon Healthcare of New Jersey(800) 355-2583www.horizonblue.comOxford Health Plans—New Jersey(800) 444-6222www.oxhp.com6. Oxford Medicare isavailable in Bergen,Essex, Hudson, Passaicand Union (North);Mercer, Middlesex andMonmouth (Center);and Ocean (South).UnitedHealthcare of New Jersey, Inc.(866) 223-5802www.uhc.comUniversity Health Plans, Inc.(800) 564-6847www.uhpnet.comWellChoice HMO of New Jersey(888) 476-6986www.wellchoicenj.com2. AmeriChoice Medicareis available only in Essex,Hudson, Passaic andUnion (North).3. AMERIGROUPMedicaid is availablein all counties exceptSalem (South).4. AmeriHealth Medicareis available only inBurlington, Camden,Cumberland, Gloucesterand Salem (South).7. University Health PlansMedicaid is availablein all counties exceptCape May (South).16PRODUCT LINE AND SERVICE AREA INFORMATION AS OF JULY 1, 20062006 New Jersey HMO Performance Report
Use the telephonenumbers andweb sites to learnmore about theHMOs thatinterest you.Service AreasCountiesNORTH:Bergen, Essex, Hudson, Morris, Passaic, Sussex,Union, WarrenHunterdon, Mercer, Middlesex, Monmouth, SomersetAtlantic, Burlington, Camden, Cape May, Cumberland,Gloucester, Ocean, SalemCENTER:SOUTH:Product Lines and Service AreasPRODUCT LINESCOMMERCIALMEDICARE991929SERVICE 99999999999999999Burlington, Camden, Ocean94999999699792006 New Jersey HMO Performance Report17
Appeals and ComplaintsThese are the steps you can take if you have been denied covered medicalbenefits or want to file a complaint.To Appeal an HMO’s DecisionYour HMO is required to have an appeal processthat gives you an opportunity to resolvedisagreements about denial of covered benefits orservices. Denials, limitations and terminations ofcovered services or benefits for such services thatresult from a decision by the HMO that the servicesare not medically necessary are adverse utilizationmanagement (UM) determinations.Review the services covered by your HMO and theexplanation of the appeal process in your memberhandbook. You or your doctor, acting with yourconsent, have the right to file an appeal of anHMO’s UM determination.Stage 1Inform the HMO, either verbally or in writing, thatyou disagree with the HMO’s decision to deny orlimit services you believe are covered and medicallynecessary. A different doctor at the HMO willconsider your request for services. You will receivenotice of whether the HMO is revising or upholdingthe initial decision.Stage 2If you are dissatisfied with the results of the Stage 1appeal, you can request, either verbally or inwriting, that the HMO have your appeal reviewed bya panel of doctors and other health careprofessionals.Stage 3If you are dissatisfied with the HMO’s decision onyour Stage 2 appeal, you can file an appeal with theDepartment of Banking and Insurance within 60days after receiving the HMO’s Stage 2 decision.You will receive the form and instructions needed tofile a Stage 3 appeal from your HMO at the sametime you receive the Stage 2 appeal decision. Yourcase will be reviewed by independent experts undercontract to the State through the IndependentHealth Care Appeals Program (IHCAP). Decisionsmade by the IHCAP are binding on the HMO.For appeals involving urgent circumstances, theHMO is required to respond within 72 hours inStages 1 and 2.To File a Complaint against an HMOIn addition to the appeal process for adverse UMdeterminations, you also have the right to complainto the HMO about any aspect of its operations. TheHMO is required to have a system to resolvecomplaints about such things as quality of medicalcare, choice of doctors and other health careproviders, and difficulties with processing claims ordisputes about an HMO’s business and marketingpractices. The HMO is required to respond to yourcomplaint within 30 days. The HMO’s memberhandbook contains a description of the process andcontact information for resolving complaints. If youare dissatisfied with the outcome of the HMO’scomplaint process, contact:NJ Department of Banking and InsuranceDivision of Consumer Protection ServicesOffice of Managed CareP.O. Box 329, Trenton, NJ 08625-0329(888) 393-1062 ( press opt
Horizon-HM Oxford WellChoice-H T he New Jersey Department of Health and Senior Services (DHSS) developed the format for this report with the cooperation of the New Jersey HMOs. DHSS was guided by an advisory group representing health plans, health care purchasers, providers and consumers. The New Jersey Department of Banking and Insurance (DOBI)
