CID: 2016 Consumer Report Card on Health Insurance Carriers in Connecticut - Text Only Version


Consumer Report Card on Health Insurance Carriers in Connecticut

Executive Summary
October 2016


Objective

Connecticut’s health insurance marketplace is dynamic as companies look for ways to better serve customers across the state. This annual consumer report card – the state’s 19th – paints a picture of the six health maintenance organizations (HMOs) and 11 indemnity insurance companies and the benefits and services they provide to over 2.4 million state residents. The data was collected from the companies by the Connecticut Insurance Department and is designed to deliver side-by-side comparisons of various health insurance plans and care measures. This report card offers consumers information on their health insurance options by providing data and trends on insurance purchasing and use.

Companies included in this report:
HMOs

Indemnity
Companies Not Included in this report:
Listed here are additional licensed companies that have managed care plans in Connecticut but were not included in this guide. These companies are not currently issuing new business. The same information found in this guide is available directly from the companies or at the offices of CID
  • Celtic Insurance Company
  • HealthyCT, Inc.
  • John Alden Life Insurance Company
  • Time Insurance Company 
  • Trustmark Insurance Company
Methodology

This data was collected by the Connecticut Insurance Department (CID) from the insurance companies. CID selected the data points, including care measures, claim denials, medical loss ratios, utilization review data, and member satisfaction survey results, based on legislation passed by the Connecticut General Assembly.

This report includes three years of data, where available, to be informative for consumers. While many of these data points are available over the 19 years since the report’s inception, there have been significant changes in insurance provisions due to the implementation of the federal Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA), and some of the data elements collected have changed over time.


Summary of Findings
Overview of All Companies

While total enrollment numbers by company have decreased slightly from the previous year, new companies have been entering the Connecticut marketplace as others exit. Moreover, there have been overall increases in the number of participating primary care providers, specialist providers, and pharmacies while the number of participating hospitals has decreased due to hospital consolidation. Moreover, most participating primary care and specialist physicians are board certified, with increases in the proportion of certified providers by company from 2013 to 2015.

Enrollment

Total Enrollment: 2,415,819

HMOs
  • Aetna Health - 23,812
  • Anthem – 215,861
  • Cigna - 32
  • ConnectiCare – 62,122
  • Harvard - 800
  • Oxford – 4,038
Indemnity
  • Aetna Life – 375,285
  • Anthem – 989,284
  • Cigna H & L – 369,962
  • ConnectiCare Benefits – 34,820
  • ConnectiCare – 141,759
  • CT General - 143
  • Golden Rule – 4,659
  • HPHC – 21,758
  • Oxford Health – 39,387
  • United – 130,982
  • United Life – 1,115

Breakdown by plan
  • 86 percent in large group plans
  • 8 percent in small group plans
  • 6 percent in individual plans

Fully insured vs Other Enrollment
  • 68 percent in other enrollment
  • 32 percent in fully insured

The total enrollment includes people with private health insurance through individual policies or through their employer’s fully-insured or self-insured plans. The enrollment does not include Medicare or Medicaid enrollees. CID has statutory authority over fully-insured plans, therefore the remainder of this book contains information on fully-insured plans and does not include information on self-funded plans, Medicare and Medicaid.

Member Satisfaction

When surveyed, members of most of the insurance plans included in this report are much more likely to classify their plans as 7 or better on a scale of 0 (worst) to 10 (best). Members also generally reported that they were always or usually able to see a specialist or obtain routine care as soon as they wanted.

Care Measures

Both HMOs and Indemnity companies are providing a range of care services to insured residents in Connecticut for preventative care, treatment, pregnancy, and mental health. Care measures reflect the percentage of the MCOs members who have accessed specific covered benefits. The “underlined care measure” indicates that, for all companies in this Report Card, at least 50% of the members who met relevant criteria used the benefit.

HMO
Preventative
  • Adult Access to Care - Age 20-44 Adult
  • Access to Care - Ages 45-64
  • Children and Adolescent Access to Primary Care
  • Childhood Immunizations
  • Immunizations for Adolescents
  • Human Papillomavirus Vaccine for Female Adolescents
  • Breast Cancer Screening
  • Cervical Cancer Screening
  • Colorectal Cancer Screening
  • Eye Exams for People with Diabetes
Treatment
  • Controlling High Blood Pressure
  • Beta Blocker Treatment After a Heart Attack
Pregnancy
  • Prenatal Care in the First Trimester 
  • Postpartum Care Following Delivery
Mental Health
  • Follow-up After Hospitalization for Mental Illness 
  • Antidepressant Medication Management

INDEMNITY
Preventative - Indemnity
  • Adult Access to Care - Age 20-44 Adult
  • Access to Care - Ages 45-64
  • Children and Adolescent Access to Primary Care
  • Childhood Immunizations
  • Immunizations for Adolescents
  • Human Papillomavirus Vaccine for Female Adolescents
  • Breast Cancer Screening
  • Cervical Cancer Screening
  • Colorectal Cancer Screening
  • Eye Exams for People with Diabetes
Treatment
  • Controlling High Blood Pressure
  • Beta Blocker Treatment After a Heart Attack
Pregnancy
  • Prenatal Care in the First Trimester 
  • Postpartum Care Following Delivery
Mental Health
  • Follow-up After Hospitalization for Mental Illness 
  • Antidepressant Medication Management

Utilization Review

Utilization Review (UR) is the process by which a health plan determines whether the treatment or services prescribed by a physician are medically necessary to treat a condition. All but one HMO saw a decrease in the number of UR requests from 2014 to 2015, while most indemnity companies had an increase in UR requests. These changes are consistent with the change in overall enrollment in these plans. While overall enrollment in all fully insured plans has declined, the enrollment in HMOs has declined at a higher rate than the decline in enrollment in indemnity plans. During the same time periods, only one HMO had an increase in denials as a percentage of UR requests, while three of the indemnity companies had an increase in the percentage of denials.

Claims Denial

While Indemnity companies had the most total claims filed (with up to 4.5 million claims received by one company), HMOs had the highest proportion of denials as a percentage of total claims (up to 30% for one company). The reasons for the denied claims also varied between the HMO and Indemnity companies, and enrollees whose claims are denied due to “not a covered benefit” or “not medically necessary” were more likely to file appeals.

Federal Medical Loss Ratio

Medical loss ratio (MLR) is the proportion of premiums spent on medical expenses or quality improvement. Under federal law, any company that does not meet the minimum loss ratio requirement may be required to pay rebates in that market. This provision adds additional consumer protections, especially in the large group market where insurance companies are not required to file rates with the Insurance Department. For 2015, most of the insurance companies included in this report met the federal standard for MLR – 85% for large group market and 80% for individual and small group markets. Only one company did not meet the 85% standard for large group MLR, and all companies met the standard of 80% for individual and small group MLR.


Terms Consumers Should Know
Here is a list of common terms used in this Report Card and in health insurance generally:
  • Adverse determination: A decision that denies, reduces, or terminates a health insurance benefit sought by an enrollee or his or her provider.
  • Board certified physician: A doctor who has passed the medical examination for a particular practice specialty.
  • Case management: A process that coordinates plans of treatment to achieve optimal patient outcomes.
  • Center for Medicare & Medicaid Services: The federal government agency that administers Medicare and oversees the state’s administration of the Medicaid program.
  • Coinsurance: A fixed percentage of the medical costs that an enrollee must pay that may be in addition to any deductible.
  • Copayment (copay): A flat fee that an enrollee must pay each time a service is used that may be in addition to any deductible.
  • Deductible: The dollar amount of medical costs in a calendar or contract year that an enrollee must pay before the plan makes any payments.
  • Drug formulary: The list of prescription drugs for use under the plan. Providers are encouraged to prescribe formulary drugs if they meet medical needs.
  • Emergency treatment: This is treatment for a condition of acute symptoms, including severe pain, in which the person would be in serious jeopardy should he or she not receive immediate medical attention.
  • Enrollee: A person and his or her eligible dependent who participates in a managed care plan.
  • Fee for service: The plan pays the provider a fee for each service provided.
  • Fully insured plan: The plan is backed by an insurance policy that guarantees benefits in exchange for premium payments.
  • Gatekeeper plan: A plan that requires an enrollee’s primary care physician to make a referral to a specialist in order for the plan to cover costs of the specialist’s services.
  • Health Maintenance Organization (HMO): With this type of organization, subscribers pay a predetermined fee (premium) for medical services. Participating providers are registered with the organization. 
  • Indemnity managed care organization (indemnity MCO): A licensed insurer that offers a managed care plan.
  • Indemnity plan: A health insurance plan that provides reimbursement for medical services covered by the plan.
  • Managed care plan: A plan offered by a managed care organization that has a network of providers and performs utilization review.
  • Managed care organization (MCO): An organization, whether HMO or indemnity insurer, that offers managed care plans.
  • Maximum lifetime benefit: The maximum dollar amount that a plan will pay out during an enrollee’s lifetime for nonessential services, such as for oral or vision care.
  • Federal Medical loss ratio (MLR): The percentage of premium used to pay claims and certain permitted expenses. 
  • National Committee on Quality Assurance (NCQA): A national not for profit that reviews plans’ quality and performance measures and confers accreditation.
  • Network: The group of providers that are under contract with an MCO to deliver medical services to enrollees for an agreed-upon fee. Generally, payments for covered services will be higher than those for out-of-network providers.
  • Point of service plan (POS): A managed care plan that permits enrollees to utilize out of network providers, at lower levels of payment.
  • Preferred provider organization (PPO): An independent group of providers that enters into a contract with an MCO to provide health services.
  • Premium: The on-going amount paid for health insurance coverage, often monthly. Premium levels are proposed by the MCOs and approved by the CID based on actuarial reviews. 
  • Primary care physician (PCP): A physician practicing General Internal Medicine, General Practice, Family Practice, General Pediatrics or OB/GYN selected by an enrollee for his or her primary care. 
  • Preauthorization: A plan may require that services or treatment be preapproved before they will be covered. Also referred to as “precertification” or “prior authorization.”
  • Provider: A physician, hospital, nursing home, pharmacy, lab, or other individual or group that provides health care services.
  • Reasonable and customary fee: The commonly charged or prevailing fee for a given health service in a specific geographic area. 
  • Referral: The request by a primary care physician to an MCO for an enrollee to receive care from an out-of-network specialist, non-participating provider or facility.
  • Self-insured plan: A group plan under which an employer takes on the risk to pay claims, but may contract with a third party to administer the plan. These plans are not overseen by the Connecticut Insurance Department but are regulated under the federal Employee Retirement Income Security Act of 1974 (ERISA).
  • Utilization review (UR): The process used by a plan to determine whether the treatment, services or setting prescribed by a provider are appropriate or medically necessary for an enrollee. It may be conducted by any organization licensed in Connecticut to perform utilization reviews.

FREQUENTLY ASKED QUESTIONS (FAQs)

The information in this report card is based on data provided by the MCOs as of year-end 2015. This report card does not contain information on specific plans offered by the MCOs. Each MCO offers several different plans, and often tailors them to a specific policyholder’s needs. You will need to get additional information from the MCO or your employer to make your choice. In addition to this report card, you will need provider directories, premium or contribution rates and schedules of benefits for each plan you are considering.

Q. What types of plans are covered in this comparison?
A. Managed Care Plans offered by HMOs or traditional indemnity companies. These plans attempt to manage the access, cost and quality of health care by promoting early detection and preventive care.

Q. How does CID get its information for this Report Card?
A. CID sends a series of surveys to the companies. Their answers to our questions are summarized and included in this Report Card.

Q. Who can I call if I have questions about the information contained in this Report Card?
A. CID’s Consumer Affairs Division at 1-800-203-3447.

Q. Does this Report Card evaluate all benefit options?
A. No. Because different plans provide different benefits, it would be nearly impossible to do so. Also, many benefits are mandated by law and therefore would be the same across plans.

Q. Who can I call if I have questions about specific benefit options?
Your employer, your insurer, or your independent agent.

Q. Does this Report Card include information regarding Medicare, Medicaid and other entitlement programs?
A. No,

Q. Does this Report Card also rate Medicare or Medicaid coverage and service?
A. No, the Report Card compares the performance of private, commercial insurers. Medicare is the federal health insurance program for people who are 65 or older and younger individuals with disabilities. Medicare information is available at www.Medicare.gov or through the Connecticut CHOICES at the Department on Aging at www.ct.gov/agingservices. Medicaid provides health coverage for low-income populations. In Connecticut, Medicaid is administered by the state Department of Social Services. More information can be found at www.ct.gov/dss.

Q. How are health insurance premiums set?
A. Under Connecticut law, individual and small group health insurance rates must be approved by CID. CID conducts an actuarial review of a health insurer’s proposed rates to determine if they are reasonable in relationship to the benefits being provided and are neither excessive, inadequate nor unfairly discriminatory. CID posts all rate requests on its web site. There is opportunity for the public to comment online or at a public hearing.

Help and Additional Information

The following state agencies, federal agencies, or nonprofit organizations also provide information concerning specific health insurance issues.

Agency: Connecticut Insurance Department Consumer Affairs Insurance
Type of inquiry: Policies, companies, producers and external appeals
Telephone: (800) 203-3447 (860) 297-3900
Website:  www.ct.gov/cid

Agency: Office of the Healthcare Advocate
Type of inquiry: Managed care problems or questions
Telephone: (866) HMO-4446
Website: www.ct.gov/oha

Agency: CT Department of Public Health
Type of inquiry: Providers and medical facilities
Telephone: (800) 842-0038
Website: www.ct.gov/dph

Agency: U.S. Department of Labor Employer
Type of inquiry: Self-funded or self-insured health plans
Telephone: (617) 565-9600
Website: www.dol.gov

Agency: National Committee for Quality Assurance (NCQA)
Type of inquiry: Care measures
Telephone: (800) 839-6487 (888) 275-7585
Website: www.ncqa.org

Agency: CT Health Channel
Type of inquiry: A single online source for CT public and private health insurance information Telephone: (877) 263-1997
Website: www.cthealthchannel.org

Agency: CT Department of Social Services
Type of inquiry: HUSKY Healthcare
Telephone: (800) 842-1508
Website: www.ct.gov/dss

Agency: U.S. Department of Health & Human Services
Type of inquiry: Information on healthcare reform and insurance options
Website: www.healthcare.gov

Agency: Access Health CT (CT Insurance Exchange)
Type of inquiry: Online source for health insurance
Telephone: 855-805-HEALTH
Website: www.accesshealthct.com


Content Last Modified on 10/24/2016 11:45:18 AM