HMO Complaint Information
The following information is Michigan HMO Complaint Data for the year 2006. Complaints can range from a consumer disagreeing with a denial of service to dissatisfaction with the service they received. An HMO is responsible for reviewing and responding to all complaints.

Please note that Medicaid members also have an external complaint process with the Michigan Department of Community Health (MDCH). This chart does not contain information from MDCH.
 
Definitions: Internal   The first formal review process conducted by the HMO
  External   The review process conducted by OFIR after a consumer has completed the HMOs internal review process. This process is called the Patients Right to Independent Review Act (PRIRA).
  Upheld   The decision of the HMO was upheld by the process.
  Overturned   The decision of the HMO was overturned by the process.
  Compromise   A mutually agreeable decision was reached.
  Resolved   The final adverse determination was reversed prior to a formal decision by OFIR.

If you have questions, please contact the Office of Financial and Insurance Regulation toll free at 877-999-6442.
 
HMO Complaint Information
    Total Level One Determinations*   External PRIRA Determinations**
Name of HMO
Upheld
Overturned
Compromise
Total
Annualized level one complaints per 1,000 members
Upheld
Overturned
Resolved 
Other#
Total
Aetna Health, Inc. 27 4 0 31 16.9 0 0 0 0 0
Blue Care Network of MI 535 477 22 1,034 2.2 25 3 1 0 29
Care Choices HMO MI 67 50 14 131 1.4 9 1 0 0 10
Community Choice MI 0 0 79 79 1.6 1 0 0 0 1
Fidelis SecureCare of MI, Inc. 5 0 25 30 76.0 0 0 0 0 0
Grand Valley Health Plan, Inc. 8 2 5 15 1.2 0 0 0 0 0
Great Lakes Health Plan 5 7 1 13 0.1 0 0 0 0 0
Health Alliance Plan of MI 643 385 73 1,101 2.5 6 2 0 0 8
Health Plan of MI 107 64 0 171 1.6 2 0 0 0 2
HealthPlus of MI, Inc. 93 146 50 289 3.0 0 0 0 0 0
HealthPlus Partners 15 21 18 54 0.9 0 0 0 0 0
M-CAID 6 6 10 22 1.2 1 0 0 0 1
M-CARE 281 301 138 720 4.3 12 3 0 0 15
McLaren Health Plan, Inc. 93 0 0 93 1.7 0 0 0 0 0
Midwest Health Plan, Inc. 1,005 508 151 1,664 29.0 0 0 0 0 0
Molina Healthcare of MI*** 91 134 453 678 2.9 0 1 0 0 1
OmniCare Health Plan 211 4 0 215 3.7 0 0 0 0 0
Paramount Care of MI 10 21 50 81 9.7 3 1 0 0 4
PHP of Mid-Michigan 188 165 0 353 5.2 11 2 0 0 13
PHPMM-Family Care 26 20 0 46 2.6 0 0 0 0 0
PHP of South Michigan 17 13 0 30 1.3 3 0 0 0 3
Physicians H. Plan of SW MI 6 4 0 10 0.4 0 0 0 0 0
Priority Health Govt. Programs 7 2 0 9 0.2 0 0 0 0 0
Priority Health Plan 345 83 11 439 1.3 5 1 0 0 6
ProCare 0 0 0 0 0.0 0 0 0 0 0
Total Health Care, Inc. 14 26 11 51 1.0 0 0 0 0 0
Total Health Care, USA 6 15 6 27 2.8 0 0 0 0 0
Upper Peninsula Health Plan 87 5 0 92 3.6 0 0 0 0 0
Year 2006 Total 3,898 2,463 1,117 7,478 2.8 78 14 1 0 93
Percent of Decisions 52.1% 32.9% 14.9%              
 

*  The source of Level One Determinations is data submitted by the HMOs to the Office of Financial and Insurance Regulation.
** The source of External PRIRA Determinations is the Office of Financial and Insurance Regulation.
*** Molina Healthcare of MI acquired Cape Health Plan 12/31/06. Totals inlcude Cape Health Plan's level one determinations.
NA - Not Available