The Office of Financial and Insurance Services (OFIS) today released the fifth annual health maintenance organization (HMO) Consumer Guide. The interactive guide is available on the OFIS web site at www.michigan.gov/ofis under "Featured Services" or by calling OFIS toll free at 877-999-6442.

"HMOs continue to be an important component in the Michigan healthcare provider network," said OFIS Commissioner Linda A. Watters. "The purpose of the HMO Consumer Guide is to equip Michigan citizens with essential information about Michigan HMOs."

The quality information in the guide is based on the Health Employer Data Information Set (HEDIS®) and the Consumer Assessment of Health Plans (CAHPS®) from the National Committee for Quality Assurance (NCQA). HMOs are measured on access/service, doctor communication/service, staying healthy services, and getting better/living with illness services. Additional information on the quality measurements is available at www.ncqa.org.

The HMO Consumer Guide contains complaint statistics required by the Patient's Right to Independent Review Act (PRIRA). This act sets up a review process for Michigan consumers who have received an adverse determination, such as a denial of a health care claim, from an HMO or other health carrier. Information about the review process is required to be provided to consumers by their HMO or other health carrier. A consumer may begin the process by:

• Promptly submitting a written grievance to the HMO or health carrier;
• Following and exhausting all steps of the HMO or health carrier's internal grievance process;
• Filing a request for external (independent) review with OFIS if the HMO or health carrier continues to maintain its adverse determination and the consumer disagrees.

The PRIRA complaint process is usually concluded by a final Order issued by the Commissioner.

In 2004, OFIS received 574 requests for review under PRIRA. Of those requests, 155 directly involved HMOs. The remainder involved BCBSM and commercial insurers. In addition to PRIRA cases, OFIS handled 291 other HMO complaints.

The HMO financial information contained in the guide tracks the solvency of Michigan HMOs. This web site is updated with PDFs of the HMO financial reports roughly 45 days after the end of each quarter and year-end. The financial information can be directly linked at www.michigan.gov/cis/0,1607,7-154-10555_12902_18956---,00.html.

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Other Health-Related Links for Information:

Michigan Family Independence Agency
www.michigan.gov/fia

Michigan Department of Community Health
www.michigan.gov/mdch

Michigan Office of Services to the Aging
http://www.michigan.gov/miseniors

Michigan Surgeon General
http://www.michigan.gov/surgeongeneral/

Michigan Association of Health Plans
http://www.mahp.org/

Michigan State Medical Society
www.msms.org

Michigan Health and Hospital Association
www.mha.org/

Michigan Osteopathic Association
www.mi-osteopathic.org