What’s behind the NCQA rankings for health-insurance plans?

These rankings of health-insurance plans are published in conjunction with the National Committee for Quality Assurance (NCQA), a nonprofit organization in Washington, D.C., that provided the data and rankings. Health plans seek accreditation from NCQA by meeting certain standards and reporting quality-of-care information and other data to it.

What types of health-insurance plans are ranked?

NCQA ranks three basic types of health-insurance plans: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans. Most people with health insurance are enrolled in one of those types of plans. PPOs are included in these rankings for the first time this year. In addition, NCQA scores and ranks health plans that serve three populations: people who get health insurance through their employer or buy it on their own in the private-sector marketplace, people with Medicare , and people with Medicaid. Plans are ranked and compared in those three categories.

How many plans are ranked?

In 2011 NCQA ranked 830 health plans in all 50 states plus the District of Columbia. There were 390 plans for people who get insurance through their employer, 341 for people with Medicare, and 99 for those covered by Medicaid.

Why isn't my plan ranked?

There are three reasons you might not see your health-insurance plan. First, not all plans submit data to NCQA. Second, those that do must authorize the release of the information to the public, and some choose not to. Third, some don't submit enough data for valid statistical analysis.

How are plans scored and ranked?

Each health plan received an overall score between 1 and 100 based on how it compared with other plans in its category (private, Medicare, or Medicaid) on enrollee satisfaction, prevention, treatment, and accreditation status. Accreditation reflects NCQA's assessment of a plan's ability to provide quality care and service. It also evaluates business operations and organization, infrastructure, and clinical programs, such as disease management and wellness.

Prevention and treatment account for 60 percent of the score for all plans; patient satisfaction and experience-of-care, 25 percent; and NCQA accreditation, 15 percent.

Plans are ranked according to their overall scores, which we've rounded—82 instead of 82.394, for example. But plans are still listed according to their original scores. So one with an initial score of, say, 82.4 will appear above one that originally scored 82.3, though the scores for both will be shown as 82.

In our analysis of health-insurance plan performance based on brand name, we identified which plans are owned by which brands using two methods: 1) a database maintained by Atlantic Information Services, Inc., which identifies corporate ownership of some health-insurance plans; and 2) looking for the brand name in the plan's name itself (for example, United Healthcare of Tennessee is owned by United Healthcare). Some plans might be owned by brands but weren't identifiable through either of those two means. As a result, they might not have been included in our analysis.

How are the scores determined?

The overall score is based on performance measures from the Healthcare Effectiveness Data and Information Set, or HEDIS®. Plans submit HEDIS data from billing and medical records as well as patient medical charts. Consumer satisfaction is based on two surveys: the Consumer Assessment of Health Providers and Systems survey, or CAHPS®; and the Health Outcome Survey (HOS). All the data we report this year, except the CAHPS assessments for Medicare plans, comes from HEDIS and CAHPS assessments for the 2010 plan year; the Medicare CAHPS data are for 2009.

For prevention and treatment measures in 2011, NCQA used 69 measures in eight areas of care, such as asthma-medication use and controlling high blood pressure. In general, private plans, Medicare plans, and Medicaid plans are graded on the same measures, but some are unique to each. For example, glaucoma screening and osteoporosis management were taken into account when evaluating Medicare plans.

NCQA summarizes the scores for dozens of individual measures in several ways. First, it scores plans on composites of related measures. When assessing diabetes treatment, for example, it considers blood-pressure control, retinal eye exams, glucose testing and control, LDL cholesterol screening and control, and monitoring kidney disease. Those composite scores are further summarized into scores for the three components of care: patient satisfaction, prevention, and treatment.

• Satisfaction considers the way patients reported the experiences of their care. It covers how they experienced a plan's doctors and its services, such as customer service.
• Prevention takes into account the proportion of eligible members who received preventive services, such as prenatal and postpartum care, cancer screenings, and immunizations. It also looks at access to primary- and preventive-care visits for children and adolescents.
• Treatment looks at recommended care for people with such conditions as diabetes, heart disease, high blood pressure, osteoporosis, alcohol and drug dependence, and mental illness.

NCQA scores all those measures on a scale of 1 to 5, from worst to best. Those that get a 5 are in the top 10 percent compared with other plans in their category, those that get a 4 are above average, those that get a 3 are average, those that get a 2 are below average, and those that get a 1 are in the bottom 10 percent.

Why are HMOs and PPOs listed separately?

HMOs and PPOs are scored and ranked on the same scales within each category—private, Medicare, and Medicaid. But we listed their rankings separately because PPOs on average score lower than HMOs. That could be for several reasons: data is collected somewhat differently; many PPOs have only recently started reporting data; and among private plans, fewer PPOs are accredited or seek accreditation.  In addition, some PPOs just might not do as well as HMOs.  See more about HMOs and PPOs.

Why is information missing for some plans?

There are several possible reasons. A plan might not offer a particular benefit or service or it might have too few enrollees using them. Or the plan might not submit data for a particular measure. NCQA differentiates between no reported data at all ("Data Not Reported") and those that a plan can't report because it doesn't offer the benefit or has too few members affected ("Not Applicable").

How should I use these rankings?

You can use them to look closely at a single plan or compare up to five plans. In either case, focus on three things. First look at a plan's 1 to 100 overall score; then see how it ranks in your state and nationally; and then look at its scores for prevention, treatment, and customer satisfaction. For even more detail, click on the plan's name and see how it did in dozens of measures, such as how well it cared for people with diabetes.

Don't focus too much on minor differences in overall scores or rank, such as between plans with scores from, say, 82 to 86 or ones ranked 70th and 80th nationally. Instead, pay attention to larger differences in overall score and rank and on the 1-to-5 scale for prevention, treatment, and customer satisfaction.

And remember that nonaccredited plans generally have lower scores than accredited plans because accreditation can add as much as 15 points to a plan's overall score.

Do these rankings apply to plans people and families buy on their own?

Health-insurance plans that people buy on their own aren't represented as often in the NCQA rankings as plans offered through an employer, Medicare, or Medicaid. And the private-plan rankings primarily reflect private employer-based coverage that companies buy for their workers, not coverage that companies "self-insure," meaning they assume the insurance risk themselves and contract with insurers to manage health-insurance benefits.

Even so, many insurers sell the same plans to self-insured companies and to individuals. But the name of the insurance product or plan and the exact benefit package might be quite different. For more details on plans offered to individuals, go to healthcare.gov.

Where can I find more details?

Go to NCQA's Health Insurance Plan Rankings 2011—Methodology Overview.

Note: HEDIS® is a registered trademark of the National Committee for Quality Assurance. Medicare data used in NCQA's rankings of health-insurance plans depends on annual approval from the federal government's Centers for Medicare and Medicaid Services. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.