Think about the steps you take before making a purchase, whether it’s an appliance or a book, or even before deciding which restaurant to go to. You want to make sure you’re getting the most for your money and will be satisfied, so you research the item, read reviews, and comparison shop. This same thinking should be applied to shopping for health insurance. The only difference is that you won’t find anything on how health plans stack up on Yelp or Trip Advisor. That’s why organizations like the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) have devised their own means of rating health plans—to help consumers, like you, find a high-quality plan that fits their needs.
NCQA Ratings For health plans everywhere in the U.S., a high NCQA rating (e.g., 4, 4.5, or 5) is the gold standard by which programs and strategies are developed, implemented, and continually improved. To an employer and consumer, a high rating indicates quality.
But first, what is NCQA exactly? In a nutshell, this organization is a private, non-partisan, not-for-profit that’s dedicated to improving health care quality by holding health plans to rigorous measures and standards that they can then use to identify opportunities for improvement.
At CDPHP, we have a team who works year-round to ensure that our programs and initiatives not only meet NCQA’s standards, but actually improve our members’ health. We use the results we receive from our annual NCQA audit to assess which measures we need to focus our time and energy on. For example, if the report indicates that not enough members are receiving their flu shots, we will step up our efforts to improve this number through mailings, newsletter articles, flu shot clinics, and other methods we deem necessary to get our message across.
In other words, NCQA, CDPHP, and other health plans nationwide share the same goal, which is to ensure that everyone has access to high-quality care. NCQA holds us accountable and motivates us to continually strive to improve so we can better serve our members.
So, why should a high rating matter? Because it demonstrates that a health plan is well-managed and committed to pursuing initiatives that result in quality care for its members, with the end goal being more lives saved, more illnesses avoided, and more costs reduced.
NCQA Accreditation NCQA accreditation status levels, which range from Denied to Excellent, are based on a health plan’s compliance with NCQA requirements and its performance on different health issues, like controlling high blood pressure, breast cancer screenings, and asthma medication use, as well as consumers’ experiences and satisfaction with health care.
To earn the NCQA seal of approval, NCQA-accredited health plans must demonstrate compliance in five key categories: access and service, qualified providers, helping members stay healthy, helping members get better, and helping members live with their illness. To assess compliance, NCQA requires health plans to undergo a survey every three years and annual reaccreditation. At CDPHP, the same multidisciplinary team ensures continuous survey readiness and is responsible for implementing compliance with new and updated standards and required elements. As a result, CDPHP has consistently received high scores and consecutive Excellent health plan accreditation status.
So why is NCQA accreditation important? Because it’s an indicator of a health plan’s quality and its ability to improve health and health care.
Medicare Star Ratings Those who are eligible for Medicare and in the market for new or different coverage should carefully weigh a health plan’s Medicare stars rating before making a final decision. Administered and determined by CMS annually, star ratings measure the quality (similar to NCQA ratings) of Medicare Advantage and Part D plans and are a helpful tool for finding the right plan that meets an individual’s unique needs. Star ratings are based on five categories:
- Staying healthy (screening tests and vaccines): Assesses whether members got various screenings, vaccines, and checkups to help them stay healthy.
- Managing chronic (long-term) conditions: Measures how often members with certain conditions got recommended tests and treatments to help them manage their condition.
- Member experience with the health plan: Takes into account how members rate the health plan.
- Member complaints and changes in the health plan’s performance: Assesses how often CMS found problems and how often members had problems with the plan, as well as how much the plan’s performance improved (if at all) over time.
- Health plan customer service: Measures how well the plan handles member appeals.
In addition to customer service, member complaints, and member experience, health plans that offer drug coverage are also rated on drug safety and drug pricing accuracy, which measures how often members with certain medical conditions are prescribed drugs that are safe and clinically recommended for their condition.
As with our NCQA ratings, CDPHP takes its Medicare stars rating seriously and has a team dedicated to ensuring that we meet CMS’ criteria every year and maintain our 5-star rating for our PPO plan and 4.5-star rating for our HMO plan.
Why is the star rating important? Because a high star rating (4, 4.5, or 5 stars) indicates that a health plan is focused on engaging members and providers, as well as investing in programs and services that support achieving and maintaining higher quality outcomes for the populations they serve.
A Commitment to Quality You may have noticed that the overarching theme throughout this post is quality. CDPHP works year-round to ensure that our members continually have access to first-rate care, as well as the tools and resources needed to stay healthy.
Compare Plans to Find the Right One If you’re in a position to choose health care coverage, whether for yourself or your employees, taking these various ratings into account will help ensure that you’re selecting a high-quality, cost-effective plan. Fortunately, NCQA and CMS make it easy to compare plans and find the one that best fits your needs.