The following information is Michigan HMO Complaint Data for the year 2008. 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 |
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The first formal review process conducted by the HMO |
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External |
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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). |
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Upheld |
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The decision of the HMO was upheld by the process. |
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Overturned |
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The decision of the HMO was overturned by the process. |
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Compromise |
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A mutually agreeable decision was reached. |
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Resolved |
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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
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Total
Level One Determinations* |
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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. |
8 |
2 |
0 |
10 |
40,000 |
0 |
0 |
0 |
0 |
0 |
BlueCaid of MI |
6 |
3 |
1 |
10 |
0.5 |
0 |
0 |
0 |
0 |
0 |
Blue Care Network of MI |
1,121 |
681 |
14 |
1,816 |
3.3 |
21 |
7 |
0 |
0 |
28 |
CareSource Michigan |
7 |
2 |
93 |
102 |
2.0 |
0 |
0 |
0 |
0 |
0 |
Fidelis SecureCare of MI, Inc. |
33 |
4 |
10 |
47 |
41.6 |
0 |
0 |
0 |
0 |
0 |
Grand Valley Health Plan, Inc. |
7 |
1 |
1 |
9 |
1.0 |
0 |
0 |
0 |
0 |
0 |
Great Lakes Health Plan |
48 |
54 |
243 |
345 |
2.0 |
0 |
0 |
0 |
0 |
0 |
Health Alliance Plan of MI |
237 |
732 |
124 |
1,093 |
2.8 |
2 |
3 |
0 |
0 |
5 |
Health Plan of MI |
122 |
76 |
0 |
198 |
1.3 |
0 |
0 |
0 |
0 |
0 |
HealthPlus of MI, Inc. |
89 |
83 |
36 |
204 |
2.4 |
0 |
0 |
0 |
0 |
0 |
HealthPlus Partners |
18 |
16 |
6 |
40 |
0.6 |
0 |
0 |
0 |
0 |
0 |
McLaren Health Plan, Inc. |
90 |
0 |
0 |
90 |
1.4 |
0 |
0 |
0 |
0 |
0 |
Midwest Health Plan, Inc. |
0 |
0 |
340 |
340 |
5.3 |
0 |
0 |
0 |
0 |
0 |
Molina Healthcare of MI, Inc. |
60 |
47 |
1,281 |
1,388 |
6.6 |
0 |
0 |
0 |
0 |
0 |
OmniCare Health Plan |
162 |
2 |
0 |
164 |
3.0 |
0 |
0 |
0 |
0 |
0 |
Paramount Care of MI |
16 |
37 |
31 |
84 |
12.0 |
1 |
1 |
0 |
0 |
2 |
PHP of Mid-Michigan |
182 |
288 |
0 |
470 |
11.0 |
14 |
2 |
0 |
0 |
16 |
PHPMM-Family Care |
9 |
29 |
0 |
38 |
2.3 |
0 |
0 |
0 |
0 |
0 |
PHP of South Michigan |
6 |
6 |
0 |
12 |
8.2 |
1 |
0 |
0 |
0 |
1 |
Priority Health Govt. Programs |
7 |
0 |
0 |
7 |
0.1 |
0 |
0 |
0 |
0 |
0 |
Priority Health Plan |
405 |
77 |
9 |
491 |
1.4 |
9 |
2 |
0 |
0 |
11 |
ProCare |
0 |
0 |
3 |
3 |
6.3 |
0 |
0 |
0 |
0 |
0 |
Total Health Care, Inc. |
65 |
15 |
8 |
88 |
1.6 |
0 |
0 |
0 |
0 |
0 |
Total Health Care, USA |
8 |
7 |
2 |
17 |
1.1 |
0 |
0 |
0 |
0 |
0 |
Upper Peninsula Health Plan |
15 |
0 |
0 |
15 |
0.6 |
0 |
0 |
0 |
0 |
0 |
Year 2008 Total |
2,721 |
2,162 |
2,202 |
7,085 |
2.9 |
48 |
15 |
0 |
0 |
63 |
Percent of Decisions |
38.4% |
30.5% |
31.1% |
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