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Guide Shows Health Plan Appeal Data and Consumer Performance Measures

How many times did New Yorkers challenge their health plans' denials of coverage and how many times did consumers win? How often did providers win?

Consumers can find out the answer to these questions and others by reviewing the Consumer Guide to Health Insurers released today by the New York State Insurance Department.

"This guide is an important resource because it enables consumers to find out how their health plan performed. It provides a comprehensive review and comparison of not-for-profit insurers, commercial insurers and health maintenance organizations (HMOs) and it shows the number of complaints, grievances and appeals filed against each health plan," Insurance Superintendent James Wrynn said.

According to data contained in the guide, consumers seeking to reverse health plans' denials of coverage won 33,921 internal appeals against commercial insurers in 2009 out of 71,787 cases closed. Consumers won 2,332 reversals in the 5,968 appeals closed against HMOs and 4,329 of the 8,946 appeals closed against non-profit insurers.

In the case of the external review process, where appeals are decided by independent third-party health care professionals, there were 812 appeals of commercial insurers' denials of coverage. Consumers won reversals, in whole or in part, 341 times. There were 570 external appeals against HMOs with consumers winning reversals or partial reversals 219 times. There were 395 appeals against non-profits with consumers winning reversals in whole or in part 162 times.

The guide also shows how each HMO compares to the average for all HMOs and reports on performance in numerous quality of care and service categories.

The average rating for all HMOs was 63. CDPHP scored the highest rating, 74; Atlantis Health Plan scored the lowest rating, 38.

CDPHP, HealthNow New York and MVP all tied for the highest score when HMO members reported receiving care quickly. CDPHP scored highest among HMOs in terms of consumer satisfaction with provider communication and breast cancer screening.

The guide also shows how HMOs performed in numerous other categories including doctor satisfaction, providing care quickly and care in connection with high blood pressure and antidepressant medication management.

The guide is prepared annually by the Insurance Department and it is available by accessing this link on the Department's website,


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