Capital District Physicians' Health Plan, Inc.

June 24, 2015Revdex.com, IncBryant Woods SouthAmherst, NY 14228Attention: ***, Complaint HandlerRevdex.com Case ID: ***Dear ***:I am writing in response to the complaint received by the Revdex.com, Incfrom the complainant identified under Revdex.com Case ID: *
***You requested a response within 14 days.All enrollment information is provided to Capital District Physicians' Health Plan, Incfrom the New York State of Health Exchange (" NYS Exchange")CDPHP did not receive the correct enrollment transaction from the NYS Exchange needed to legally enroll the complainant's daughterShortly after receipt of your complaint, we wrote to the NYS Exchange regarding the complainant's situation and requested the proper enrollment transactionTo date, we have notyet received itAs the NYS Exchange is the controlling body, CDPHP is not permitted to unilaterally enroll the complainant's daughter without receiving the proper enrollment transactionWe will reach out again in an attempt to secure the required enrollment transaction from the NYS Exchange.Sincerely,Randy R***Director, Corporate ComplianceCapital District Physicians' Health Plan, Inc

Revdex.com:I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.I find the news pleasing that CDPHP now has an in network provider in Reproductive EndocrinologyHowever, over the ~six month period of time that my wife tried to receive care from a reproductive endocrinologist we were unable to do so (including the referenced doctor)It does us little good that now, after being denied care for ~six months, filing appeals and pleading our case on numerous occasions to no avail, and ultimately leaving the company due to denial of care, that CDPHP is deciding to offer care to current customers in reproductive endocrinologyAs such, this does nothing to resolve the issue that CDPHP was so willing to take our premium payments and unwilling to help us find a doctor until after we left the company and filed a Revdex.com complaint.Regards,*** *** ***

I am writing in response to the complaint received on behalf of Ms***Attached is the March 3, 2016CDPHP response provided to Ms*** with regard to the complaint filed directly with CDPHP and the Revdex.com.Please be advised, the provided response and attachment(s) contains member specific and
sensitive informationwhich was authorized by Ms*** to be released to your companyWhile CDPHP takes no responsibility onyour company’s further use, publishing, or disclosure of this information, we would expect you to understandthe sensitive and confidential nature of the enclosed information and to act in accordance with the law as to itsuse and disclosure

I am writing in response to your letter dated January 17, that was received by Capital District Physicians’ Health Plan, Inc(“CDPHP”) which is regarding a complaint filed by Ms*** ***As referenced in Section XIII of Ms.***’s contract (attached), Participants are eligible
to receive points percontract, per calendar year for completion of various programs and activities focused on improving health and wellness of the memberThe eligibility period of the program is on a plan year basisAll activities must be complete and points must be earned and redeemed within your plan yearAny points not redeemed by the last day of the plan year will be forfeited.Our records indicate that Ms*** did not redeem her Life Points by December 31, Therefore, any points accumulated were forfeitedCDPHP placed a warning message on the Life Points site reminding members to redeem their points, in addition to written correspondence that was sent to members.Sincerely,Randy ***Director Corporate Compliance Capital District Physicians' Health Plan Inc

Good afternoon ***, I am writing in response to the complaint received on behalf of Ms***Life Points is a member-specific program, controlled by the member, not the subscriberThe goal of the program is for a specific member to earn incentives for participating in a variety of
health-supportive activitiesPoints are setup under a member specific accountAs the attached Terms and Conditions indicate in the second paragraph, these incentive programs are available only to eligible members who maintain their coverage with CDPHPCDPHP’s policy provides that once a member’s coverage ends they are no longer eligible to participate in the incentive program nor will they be allowed to redeem any earned points.Our records indicate that the dependent member’s coverage ended with CDPHP on 3/31/Therefore, any member-specific Life Points earned would have needed to have been redeemed by the member prior to the dis enrollmentNicholas *** Corporate Compliance Coordinator CDPHP

Revdex.com:I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint.
While the terms state "CDPHP’s policy provides that once a member’s coverage ends they are no longer eligible to participate in the incentive program nor will they be allowed to redeem any earned points' CDPHP fails to acknowledge that I am NOT asking for the member to participate, I am NOT asking for the member to be able to redeem the points
I am asking that the points to be returned to the program, allowing them to be earned by other family members who remained covered for the duration of the termThere is NOTHING in the terms of this program that state a member cannot return the points and since there is nothing stated that this cannot be done, this is what I am requesting is done to resolve this issue
Finally, if CDPHP is sincere about giving rewards as an incentive for healthy behaviors, they should give them periodThis give and then take back is a shady business practice
respectfully,
*** ***

I am writing in response to your letter dated May 4, that was received by Capital DistrictPhysicians’ Health Plan, Inc(“CDPHP”) on May 5, and which is regarding a complaint filed by Ms*** ***.The Health Insurance Portability and Accountability Act of (“HIPAA”) prohibits CDPHP
from disclosinginformation pertaining to Mr*** without a valid written authorizationI have enclosed CDPHP’s“Authorization to Release Health Information” form for completion by Mr***The same form can alsobe found at CDPHP.com, Members, Forms and DocumentsUpon receipt of the completed and signed form,CDPHP will respond with our position to this requestPlease notify me if the complainant advises thecompleted authorization was sent directly to CDPHP.Sincerely, Nicholas ***Corporate Compliance CoordinatorCapital District Physicians’ Health Plan, Inc

Revdex.com:I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint.
I have reviewed the terms of the ProgramI am NOT asking to allow the member to participate or redeem points after his coverage ended
I am asking for the points to be RETURNED so that other members of the family may EARN them if possibleThere is NOTHING in the terms of the program that say a member cannot do thisAlso, I repeatedly notified *** over times that points were erroneously credited to that member, I was reassured they would be corrected and it was not doneEach year I also have to chase after getting any Cafewell points properly credited as wellNo matter how much time goes by they don't show up in my account until I send multiple emails questioning it ("we are looking into it" "we can't find your account" "I'm sorry, what was your user name again?")
Regards,*** ***

Good afternoon Jeff, Please be advised, in order to furnish a complete reply regarding the matter, CDPHP has provided correspondence previously provided to the enrollee, which contains identifying and sensitive information. This information has been provided, because of the authorization
Mrs*** *** supplied to CDPHP on your companies' behalf. Discretion should be used with regards to publishing this responseThank you, Nicholas *** CDPHPCorporate Compliance Coordinator

I am writing in response to the follow up comment received
regarding the complaint for Mrs*** ***.
CDPHP has further investigated the complainant’s claim that no
*** *** within the CDPHP network is available to see Mrs** *** Dr*** ***;
*** ***, and participating provider with CDPHP’s network
was provided to Mrs*** *** as an in-network option. Additionally, CDPHP has recently outreached
to *** *** office and confirmed that they are currently accepting new
patients and able to see Mrs*** *** at the below address. With regards to the complainant’s reason for not appealing
with the Office of *** *** (***) due to the length of time for a
decision to be made on the matter; CDPHP does not have jurisdiction over the
timeframes in which *** provides or takes to make a determination on a *** *** appeal. As stated in my
previous response, CDPHP provided the member appropriate information on requesting
further review, at the time of the denial, and additionally is available to her
in the FEHB brochure

Good morning ***, Please see the attached response. Thank you, Nicholas ** ***CDPHP Corporate Compliance Coordinator I am writing in response to the follow up comments received regarding the complaint Ms***. CDPHP has further investigated the complainant’s statement that points were erroneously awarded to her dependent’s Life Points account. Upon review, it was confirmed that the points in question were self-reported by Ms***’ dependent, and as such, appropriately applied to that portion of the policy. In accordance with the terms and conditions previously provided, “CDPHP’s policy provides that once a member’s coverage ends they are no longer eligible to participate in the incentive program nor will they be allowed to redeem any earned points.” Consequently the above mentioned points were unclaimed by the dependent at the time his coverage ended with CDPHP and were forfeited.The Life Points program allows the family to collectively earn and redeem a total of points per plan year. As indicated above, earned points are not recirculated into available points for the remainder of the family to potentially earn again, should an enrollee terminate before redeeming Randy ***Director, Corporate Compliance Capital District Physicians’ Health Plan, Inc