The information in this report card comes from the opinions of consumers and from health plan records. For some measures, consumers’ opinions and experiences were collected in the spring of 2010 using a confidential member satisfaction survey known as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®), which is a program of the U.S. Agency for Healthcare Research and Quality (AHRQ).
For other measures, health plans reported information from their records about the services they provided during 2009, using a standard set of measures called the Healthcare Effectiveness Data and Information Set, or HEDIS®. HEDIS® is a widely used set of clinical quality measures that requires plans to collect information in a way that allows for fair comparisons. HEDIS® is developed and maintained by The National Committee for Quality Assurance (NCQA), a non-profit organization dedicated to improving health care quality.
Can I trust this information?Yes. The health plans did not administer the CAHPS® survey to their members. Instead, an independent organization, certified by NCQA, administered the survey and provided the results to each health plan. In much the same way that financial information can be audited to make sure it is accurate, independent organizations used nationally-recognized audit standards to check the HEDIS® results reported by the health plans. HEDIS® requires health plans to collect information in the same way so that the plans can be compared fairly.
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS® is a set of standardized performance measures designed to help purchasers and consumers make reliable comparison of organization performance.
NCQA is an independent, non-profit organization that accredits and certifies a wide range of healthcare organizations and manages the evolution of HEDIS®, the performance measurement tool used by more than 90 percent of the nation’s health plans.
National Committee for Quality Assurance (NCQA), Washington, D.C.: HEDIS® 2011 Technical Specifications, Volume Two. The source for national data contained in this publication is Quality Compass® and is used with the permission of NCQA. Any analysis, interpretations or conclusions based on this data is solely that of the authors and NCQA specifically disclaims responsibility for any such analysis interpretation or conclusion. Quality Compass® is a registered trademark of NCQA.
Public reporting of health care information is a critical priority of the Vermont Department of Banking, Insurance, Securities and Health Care Administration. Each year, the Department publishes this health plan report card so consumers can compare the performance of health plans in Vermont to see how health plans performed during the most recent reporting period for measures of Experience of Care and Service, Preventive Care, Acute Illness Care and Chronic Illness Care. Each health plan’s score is compared to the national average and the New England average, which is often higher than the national average.
If you have had services which have been denied and you think they should be covered, talk with your doctor or health care provider or call your health plan to get help understanding the plan’s decision.
If you are still not satisfied, tell your plan you want to file a complaint (grievance). You must complete the plan's internal process.
If you are still unhappy with your plan’s decision, you may have the right to get an independent review of that decision.
If you have an emergency and need to request an external appeal (and it cannot wait for normal business hours), please call the External Appeals answering service at (888) 236-5966. Your call will be returned as soon as possible. This number is ONLY for Health Insurance appeals. If your appeal is not an emergency or medically urgent, please do not use this emergency number, but call again during normal business hours.
You must request an external independent review within 120 days or 4 months (whichever is longer) of receiving the final denial letter from your insurer. Call Consumer Services at 1-800-964-1784 or 802-828-3302 as soon as possible to find out if you qualify.
To qualify for an independent external review, the insurer must have denied coverage for one of the following reasons:
The service is not medically necessary, or
The selection of a health care provider is limited in a way that is not allowed by your contract or by law, or
The service is considered to be experimental, investigational, or an “off-label” use of a drug, or
A medically based decision was made that your condition was “pre-existing”, and
Was a covered benefit under you plan.
If it appears that you qualify, you may complete the attached application or ask us to send you an application. There is a $25 filing fee that may be waived. We will collect documents from you and the insurer and submit them to the Independent Review Organization (IRO). Decisions by the IRO are made within 30 days of receiving all information.
If your case is medically urgent or an emergency, time frames can be shorter. Call us immediately. Your medical information will be kept confidential.
Below please find a list of frequently asked questions and answers about flood coverage. Please do not hesitate to contact Consumer Services Department if you have additional questions:
Vermont Department of Insurance
Consumer Services
1-800-964-1784 (in state long distance) or 1-802-828-3302
Email: BISHCA.consumer.services@state.vt.us
QUESTION: My home was damaged by water when the flood entered my home. Will my homeowner's policy pay for the damages?
ANSWER:
Homeowner (HO), renters, condominium and farmowners policies—These standard policies do not cover water damage due to flood for either the building or personal property. There is no endorsement available to add coverage.
Mobile home policy (MHO—The basic MHO policy does not cover water damage due to flood for the structure or personal property.
Commercial property policy (CP—The standard CP policy does not cover water damage due to flood to the building or business personal property. However, some carriers have added limited coverage to their deluxe policies or can add this limited coverage by endorsement.
National Flood Insurance policy—The National Flood Insurance policy covers loss due to water damage resulting directly from flood. Buildings and contents must be stated separately.
QUESTION: My home was damaged by water seeping through the basement walls. Will my homeowner's policy pay for the damages?
ANSWER:
Homeowner (HO), renters, condominium and farmowners policies– These standard policies do not cover water damage due to the seepage of water through the walls or floor of a basement. There is no endorsement available to add this coverage.
Commercial property policy (CP)—The standard CP policy does not cover water damage due to seepage for the building or business personal property.
National Flood Insurance policy—The National Flood Insurance policy provides coverage for these losses only when they occur in conjunction with a general condition of flooding in which the insured property has been, at the same time, damaged by flood.
QUESTION: My home was damaged by water and sewer material when the sewer backed up into my basement during the flood. Will my homeowner's policy pay for the damages?
ANSWER:
Homeowner (HO), condominium and farmowners policies—These standard policies do not cover water damage due to the backup of sewer. Insurance companies, however, offer endorsements to provide coverage for sewer backup. Some of these endorsements still exclude coverage if backup is due to a flood while some companies offer backup coverage even if the cause was flood.
Renters policy—The standard renters policy does not cover water damage due to sewer backup for personal belongings. There is no endorsement available to add coverage.
Commercial property policy (CP) —The standard CP policy does not cover water damage due to sewer backup for the building or business personal property. Some companies may offer coverage by endorsement.
National Flood Insurance policy—The National Flood Insurance policy provides coverage for sewer backup even if the flood water has not touched the house if there is a general condition of flooding in the area and the flood was the proximate cause of the seepage.
QUESTION: My home was damaged by water when the sump pump failed and water backed up into my basement during the flood. Will my homeowner's policy pay for the damages?
ANSWER:
Homeowner (HO), condominium and farmowners policies—These standard policies do not cover water damage due to the failure of a sump pump for either the building or personal property. Some insurance companies, however, offer endorsements to provide coverage for sump pump failure. Some of these endorsements still exclude coverage if failure is due to a flood while some companies offer coverage even if the cause was flood.
Renters policy—The standard renters policy does not cover water damage due to failure of sump pump for personal belongings. There is no endorsement available to add coverage. Commercial property policy (CP)—The standard CP policy does not cover water damage due to a sump pump failure for the building or business personal property. Some companies may offer coverage by endorsement.
National Flood Insurance policy—The National Flood Insurance policy does not cover sump pump failure.
QUESTION: How do I file a claim if I have purchased federal flood insurance?
ANSWER: Consumers who have purchased a flood insurance policy should contact their insurance agent for help in filling out claim forms. If you have questions on your flood insurance or you need help in locating your flood insurance company, you may call 1-800-427-4661.
QUESTION: During the course of fighting the flood, someone drove their vehicle across my lawn causing damage. Is there any coverage for the lawn?
ANSWER: Homeowners policy (HO)—The standard homeowner policy provides an additional coverage for damage to the lawn caused by vehicles not owned or operated by a resident of the premises. The amount of coverage is generally five percent of the dwelling limits.
Commercial property policy (CP)—The standard commercial property policy does not provide coverage for damage to lawns caused by vehicles.
QUESTION: The power failed somewhere off of my premises and caused my refrigerator/freezer to fail resulting in food spoilage. Is there any coverage?
ANSWER:
Homeowner (HO) and farmowners policies—These standard policies do not cover food spoilage as a result of power failure off premises. Some comprehensive policies, however, have added a limited amount of coverage, i.e., $500, while other companies will provide an endorsement to cover food spoilage.
Commercial property policy (CP)—The standard CP policy does not cover food spoilage due to power failure. Most companies offer coverage through the use of an endorsement.
National Flood Insurance policy—The National Flood Insurance policy does cover loss of refrigerated products but only if caused by flood. Power failure for other reasons would not trigger coverage under this policy.
QUESTION: I had to leave my home because of a mandatory flood evacuation. Are my additional living expenses covered?
ANSWER:
Homeowner (HO), condominium and farmowners policies—These standard policies provide loss of use and additional living expenses for any covered peril. Since flood is not a covered peril; there is no coverage under the policy.
National Flood Insurance policy—The National Flood Insurance policy does not provide coverage for loss of use or additional living expenses.
QUESTION: When the flood waters receded, it left a large amount of debris on my property. Is there coverage for removal of this debris?
ANSWER:
Homeowner policy (HO)—The standard HO policy covers debris removal if a covered peril causes the loss. Since flood is not a covered peril, there would be no coverage.
Commercial property (CP)—The standard CP policy provides coverage for debris removal if a covered peril causes the loss. If the standard CP policy provides coverage for flood, then debris removal would be covered.
National Flood Insurance policy—The National Flood Insurance policy does cover debris removal resulting from a flood within the total limits of coverage. This applies whether it is debris from off of your premises or debris from your property or premises.
QUESTION: At one time I purchased "special coverage" for some of my personal property, which was added to my homeowners policy. Are these items covered for flood?
ANSWER:
Homeowner (HO), renters, condominium and farmowner policies - The following types of personal property can be scheduled or specifically listed in an endorsement to the standard policy: jewelry, furs, computer, cameras, musical instruments, silverware, golf equipment, fine arts, postage stamps and rare and current coins. This endorsement does not exclude flood; therefore, those items could have coverage for flood damage.
QUESTION: I had to close my business because of the flood. Will insurance cover my lost income?
ANSWER:
Commercial property policy (CP)—The standard CP policy may provide business income protection within the policy or by endorsement. The coverage only applies to a covered cause of loss. Therefore, if the policy provides flood coverage, the coverage also applies to business income.
National Flood Insurance policy—The National Flood Insurance policy does not provide coverage for loss of use, loss of access, business interruption, additional expense or loss of profits.
QUESTION: My vehicle was covered by the flood water. Will the damage be covered by my auto policy?
ANSWER: If you carry comprehensive coverage on your automobile policy, then you would have coverage for damage caused by a flood.
QUESTION: Are there any other types of losses and insurance coverages I should be aware of?
ANSWER:
Boats—Boats may be covered by a separate endorsement to a homeowners policy or by a separate boat owners policy.
Livestock losses—The farmowners policy may provide coverage for livestock on a blanket or schedule basis. Also, animal mortality policies provide coverage for drowning.
Farm equipment—Farm equipment is usually not covered, although some farmowners policies may provide some specific coverages.
QUESTION: Who can I call if I have more insurance coverage questions?
ANSWER: You should first try to contact your local insurance agent or your insurance company for specifics about your policy.
For general flood insurance policy questions, call the NFIP help desk at 1-800-427-4661.
For National Flood Insurance Program claims, call 1-800-638-6620.
QUESTION: If I have problems with my insurance company, agent, or adjuster, where can I turn?
ANSWER: If you believe you are being treated unfairly, you may file a complaint with the Vermont Insurance Insurance Department. You may call the Department's consumer hotline at 1-800-964-1784 or locally at 802-828-3302 for assistance.
