NCQA’s Health Insurance Plan Ratings 2019-2020

Ratings Project Announcement—March

• Message sent to HEDIS and Accreditation staff, medical director, CEO, marketing manager.
• This announcement alerts plans that NCQA will rate plans in 2019.

Plan Confirmation—Late May

• (Action Required) Confirmation of the HEDIS and CAHPS submissions and other information used (e.g., organization name, states, Accreditation status) to calculate ratings. Plans have 10 business days to confirm.

HEDIS and CAHPS Submission—June 17

• This submission deadline is defined in the HEDIS Volume 2 Technical Specifications.

Projected Ratings—August 6, 2019

• (Action Required) Confirmation of Accreditation status and overall rating, or 1 of 3 reasons a rating cannot be calculated:
  • Partial Data Reported: The plan submitted HEDIS data, but not CAHPS data (or vice versa); or the plan earned an NCQA Accreditation status that does not require HEDIS.
  • No Data Reported: The plan did not submit data or opted not to report data publicly.
  • Low Enrollment: The plan did not submit data or opted not to report data publicly, and its enrollment is fewer than 8,000 members.
• Plans have 10 business days to confirm.

Final Ratings—Early September

• A private release of final ratings to all plans.

NCQA Releases Ratings—September 20

• Final ratings posted on healthinsuranceratings.ncqa.org.
• Embargo on plan rating-related promotions ends at 6:00 p.m. ET; plans may begin advertising their ratings at this point.

Questions? Contact NCQA’s Health Insurance Plan Ratings Help Desk at  my.ncqa.org.

How do the ratings work, in brief?

NCQA’s ratings methodology displays the overall rating (in half-point increments) on a scale of 0–5, where 5 is the highest score and 0 is the lowest score.

Individual measures are rated in whole points against all lines of business for the 10th, 33.33rd, 66.67th and 90th measure percentiles. Percentiles will be available in Quality Compass 2019 for all measures and product lines, except for Medicare CAHPS and HOS measures that are not reported in Quality Compass.

2019 ratings will not include Exchange plans because they have not developed sufficient data for analysis.

What are the rating categories?

Plans fall into one of three categories:

1. The plan submitted both HEDIS and CAHPS data for public reporting (regardless of its Accreditation status) and is assigned a score from 0–5, in half point increments.
2. Partial Data Reported. More than 50 percent of the weight of the plan’s submitted measures are “NA” or “NB,” or
   • The plan submitted HEDIS data but did not submit CAHPS data (or vice versa), or
   • The plan earned an NCQA Accreditation status that does not require HEDIS, and did not submit HEDIS or opted not to publicly report data.

3. No Data Reported. The plan did not submit data or opted not to publicly report data.

What plans are included in the ratings?

All plans that submit both HEDIS and CAHPS for public reporting are eligible for ratings. All HMOs, POS organizations and PPOs with coverage in the 50 states, DC, Guam, Puerto Rico and Virgin Islands are included in the ratings.

Plans are rated separately by product line: private, Medicaid and Medicare. PPO, HMOs and POS plans (HMO; EPO, HMO/EPO combined, POS; HMO/POS combined; PPO; HMO/PPO combined; HMO/POS/ PPO combined; POS/PPO combined) report on the same measures and are compared in the same list.

All Medicare plans required by CMS to submit HEDIS are included in the published ratings. Medicare plans that are not required by CMS to submit HEDIS are not included in the published ratings unless they have earned NCQA Accreditation.

Note: Ratings do not include Exchange plans or Medicare Supplemental plans.

How does NCQA define “state coverage”?

NCQA defines “state coverage” as the states where a plan is licensed to operate. Plans that submit HEDIS/CAHPS data provide this information each year during the HOQ process.

If plans do not submit these data, NCQA uses state licensing and membership data provided for Accreditation or gathered from external sources.

How do the ratings display information of Accredited plans vs. nonaccredited plans, or plans that report publicly vs. plans that do not report publicly?

• Plans that are NCQA Accredited with HEDIS and marked their submission “Not Publicly Reported” on the Attestation are eligible for ratings. All measures are used to calculate the overall rating, but only scores for measures required for Accreditation are displayed. Measures not required for Accreditation are displayed as “Not Public [NP].”
• Plans that are not NCQA Accredited and marked their submission “Not Publicly Reported” on the Attestation, or that do not submit HEDIS or CAHPS data, are displayed as “No Data Reported” in the ratings and receive “No Credit [NC]” for the display of their measure information. Non-reporting plans with enrollments of fewer than 8,000 members are not listed in the report.
• Plans that are NCQA Accredited Standards Only or Interim and marked their submission “Not Publicly Reported” on the Attestation are displayed in the ratings as “Partial Data Reported” and all measures are displayed as “No Credit [NC].”
• Plans that are NCQA Accredited Standards Only or Interim and marked their submission “Yes” to public reporting on the Attestation are rated on the data they submitted.

How does NCQA weight measures in the ratings?

Weights align with Medicare Stars ratings and other programs, and are assigned as follows:

• “1” =Process measures (e.g., screenings, visits).
• “1.5” =Patient experience measures (CAHPS).
• “3” =Outcome measures (e.g., HbA1c Control, BP Control).

What measures are included in the ratings methodology?

Measures included in the ratings are listed in the Methodology Overview appendix. Measures are removed from the methodology if less than 40 percent of plans provide a scorable rate (not “Not Applicable [NA]” or “No Benefit [NB]”). The final measure list is based on NCQA’s discretion. Additionally, some measures are excluded from the ratings based on the following rules:

• Where there were paired process and outcome measures (e.g., HbA1c screening and HbA1c control), we typically kept the outcome measure.
• Where there were paired process measures (e.g., initiation and engagement), we kept one of the pair—usually, the measure that was the continuation or engagement indicator.

Scoring – Risk Adjusted Utilization Measures

Plan All-Cause Readmissions (PCR), Emergency Department Utilization (EDU), Acute Hospital Utilization (AHU) and Hospitalization for Potentially Preventable Complications (HPC) are case-mix adjusted measures. AHU and HPC (Medicare only) are new to HPR 2019.

The traditional scoring model was modified: PCR is reported as a ratio of observed to expected (O/E) hospital readmissions; EDU is reported as O/E emergency department visits; AHU is reported as O/E acute hospital discharges; HPC is reported as O/E hospital discharges for ambulatory care sensitive conditions.

To identify meaningful distinctions between plans, NCQA will distinguish between three levels of performance using statistical significance testing; better-than-expected performance, lower-than-expected performance and same-as-expected performance. Before evaluating the plan’s O/E thresholds as outlined below, the plan’s ratio and upper/lower confidence limits need to be calibrated to determine what percent above or below the national average the plan’s ratio is. In order to calibrate the O/E ratio, divide the plan’s ratio and upper and lower confidence limits by the national average O/E ratio. This calibrated value is then compared to 1.0 for scoring.

• A calibrated O/E ratio >1.0 means the plan had a below average O/E ratio, based on its case mix.
• A calibrated O/E ratio <1.0 means the plan had an above average O/E ratio, based on its case mix.

Plans with fewer than 150 denominator events (Count of Index Stays for PCR, Total Number of Members in Eligible Population for EDU, AHU and HPC) are scored NA. To help protect against trivial (though statistically significant) differences, we use an effect size threshold of 0.9 and 1.1.

Calibrated O/Es must be significantly different from 1.0 and exceed the upper and lower thresholds; therefore, these measures use a 3-point scale to determine low, medium and high levels of performance that we have mapped to HPR’s 5-point scale.

To calculate the upper and lower confidence limits (CL) for scoring, we apply the formulas below using the reported values in the measure. Table 1 outlines the points earned for each group of plans.

1. Upper CL = ((Observed Count+(1.96*sqrt(variance)))) ⁄ (Expected Count))
2. Lower CL = ((Observed Count-(1.96*sqrt(variance)))) ⁄ (Expected Count))
3. Calibrated Upper CL = (Upper CL  ⁄  National Average O/E)
4. Calibrated Upper CL = (Lower CL  ⁄  National Average O/E)

Note: NCQA will calculate the confidence limits for all organizations.

How does NCQA handle missing values?

Plan measures may have “missing values” (Not Reported [NR], Not Required [NQ], Biased Rate [BR], Not Applicable [NA] and No Benefit [NB]). NA and NB measures are not scored in the ratings; NR, NQ, and BR measures receive a rating of “0” (zero). NR, NQ and BR scores are included in composite and overall calculation of ratings. For more information, refer to What are the rating categories?

To determine if plans have insufficient data for ratings, we test whether rates are based on at least 50 percent of the data by weight. To do this, the program combines all measures by plan, then identifies whether the plan has scorable (non-NA or NB) data for at least 50 percent of the weight of measures that make up the overall score. A plan that does not meet the threshold is assigned a “Partial Data Reported” rating status.

What plans are rated?

To be rated, private (commercial), Medicaid and Medicare plans must submit scorable (non-NA or NB) rates for at least 50 percent of the weight of measures, and must submit both HEDIS and CAHPS data. Plans with partial data or no data, or that do not publicly report data, are not rated, but will be listed.

Rated plans and plans with partial data are scored on the measures they submit if they elect to publicly report. Refer to Conditions for Public Reporting.

Overall rating

The overall rating is rounded from a multi-decimal rating to one decimal place. For example, a raw rating of “3.749999” rounds down to “3.5”; a rating of “3.750111” rounds up to “4.”

What is HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a tool that measures health plan performance on dimensions of care and service. HEDIS 2019 comprises 92 measures across multiple domains of care, and is used by more than 90 percent of America’s health plans. Because so many plans collect HEDIS data, and because the measures are specific, health plans can be compared on the same things—on an “apples-to-apples” basis. Health plans also use HEDIS results to identify areas that need improvement.

How are HEDIS data reported to NCQA?

NCQA collects HEDIS data directly from health plans through online portals. Read more about HEDIS data submission.

What is Accreditation’s role in the ratings?

NCQA Accreditation accounts for up to 10 percent of the weight of valid submitted measures and serves as bonus points. NCQA uses the June 30 Accreditation status and any status modifiers for the ratings display. For example, if as of June 30, a plan was “Under Review by NCQA,” its Accreditation status is “Yes—Under Review by NCQA.”

How do health plans earn Accreditation points?

Health plans earn points by going through NCQA Accreditation, an independent review of health plan systems, processes and results on multiple dimensions of care, service and efficiency. An NCQA Accreditation Survey involves onsite and offsite evaluations conducted by a survey team of physicians and managed care experts. Read more about NCQA Accreditation process.

How is the Accreditation score included in the ratings?

The “actual” standards score is divided by the “possible” standards score and multiplied by 5 (the highest rating [i.e., actual/possible x 5]) and then multiplied by 10 percent of the weight of the valid measures. The Accreditation score is then added to the sum of the HEDIS and CAHPS weighted ratings points.

• Accredited plans may increase their overall rating by up to a half-point.
• Interim Accredited plans may increase their overall rating by one-third the amount that Accredited plans can.
• Nonaccredited plans receive a score of “0” (zero) on the Accreditation score.

How are nonaccredited plans rated against Accredited plans?

Nonaccredited plans as of June 30 receive an Accreditation score of “0” (zero), but can receive points for publicly reported HEDIS and CAHPS data.

Plans that are scheduled for an NCQA Accreditation Survey or are in the survey process as of June 30 receive a score of “0,” but are listed as “NCQA Accreditation = No (Scheduled)” or “NCQA Accreditation = No (In Process)” on the final report.

What is CAHPS?

The CAHPS (Consumer Assessment of Healthcare Providers and Systems) 5.0 survey, included in HEDIS, measures member satisfaction in areas such as claims processing, customer service and getting needed care quickly. For more information about CAHPS, go to https://www.ahrq.gov/cahps/surveys-guidance/index.html.

Is the CAHPS survey given to all health plan members, or to a random or stratified sample?

The survey goes to a random sample of plan members.

Who administers the CAHPS survey and collects the data?

Certified survey vendors administer the survey and collect the data. Commercial and Medicaid CAHPS data are submitted to NCQA; Medicare CAHPS data are submitted to a CMS contractor.

What is the role of the Medicaid CAHPS component in the ratings?

Medicaid plans have the option to be scored on either Adult CAHPS or Child CAHPS data. Plans make this selection through the Healthcare Organization Questionnaire (HOQ) in February. Both NCQA Accreditation and Health Plan Ratings use the same plan’s CAHPS component selection.

How do Medicare CAHPS and Health Outcome Survey (HOS) affect the ratings?

Due to the timing of Medicare CAHPS and HOS, NCQA uses the prior year’s data for ratings. For the 2019 Health Plan Ratings, NCQA will use Medicare HEDIS 2019 data, but use Medicare CAHPS and HOS 2018 data.

Why are plans required to affirm their projected rating?

NCQA requires plans to review their projected rating as a final quality assurance step in the ratings process. Although the projected information is subject to change (from continued quality checks), plans must affirm that they reviewed their information and have no questions regarding their Accreditation status or projected rating.

What’s the difference between HOQ, plan confirmation, IDSS and projected ratings?

• The Health Organization Questionnaire (HOQ) is released in January. It requires plans to identify and create submissions for the upcoming HEDIS and Accreditation programs.
• Plan confirmation is a ratings-specific process that is released in May/June. All plans must confirm that NCQA has accurate information (e.g., plan name, Accreditation status, states) on each plan eligible for ratings.
• Plans use the Interactive Data Submission System (IDSS) to submit HEDIS and CAHPS data to NCQA. Data are used in the ratings, in addition to plans’ scores on the Accreditation standards. The HEDIS Attestation, required with each HEDIS submission, determines how a plan will be scored and displayed in the ratings.
• Projected ratings are the plan’s current rating scores and are made available in early August. All plans must confirm their information.

How does NCQA determine a plan’s Accreditation status?

Accreditation status is based on NCQA’s records as of June 30. NCQA also uses status modifiers, such as “Under Review by NCQA,” if a plan has one as of June 30.

If you think we identified your plan’s status incorrectly, contact https://my.ncqa.org immediately.

Why is our submission ID “0”?

There are two reasons why this might happen:

1. Your plan is NCQA Accredited, Interim, Scheduled or In Process, but is not required to submit HEDIS data and only submits standards data via the Interactive Review Tool (IRT).
2. Your plan does not submit data to NCQA, but is eligible to be included in the ratings based on our research.

Why are only some of our submissions listed?

NCQA ratings exclude some submission types:

• FFS plans.
• Special projects or state-specific submissions.
• Exchange plans.

Only plans eligible for NCQA programs and validated during the plan confirmation process are included in the ratings.

Our plan does not want to be included in NCQA’s Health Plan Ratings or does not plan to submit data to NCQA. Will we be listed in the ratings?

Yes. NCQA includes all eligible plans in the ratings. Refer to How do the ratings display information…, above.

How can our plan update its information?

Plans can update certain information (URL, state coverage area) during the plan confirmation process in May/June. NCQA reserves the right to approve all changes. Because plans can have multiple submissions that are licensed to operate in multiple states, NCQA reserves the right to change a plan’s name, to distinguish submissions.

What source is used for the “SNP Only” identifier?

CMS provides a list to NCQA that identified Medicare Advantage contract numbers containing SNP-only members. NCQA will identify these plans in the final ratings list with a superscript identifier after their name.

Are there duplicate plans on the ratings list?

No. Some plans have similar names but are distinct legal entities. NCQA’s policy requires them to be listed separately and attempts to differentiate plan names where possible.

Our plan is not listed in the ratings. Why?

Nonaccredited plans that do not publicly report and have an enrollment fewer than 8,000 members are not listed in the ratings.

Our Medicare plan is not listed in the ratings. Why?

NCQA only lists Medicare plans that are required to submit HEDIS by CMS or are NCQA Accredited. Use of Medicare data in the NCQA ratings methodology depends on yearly CMS approval. NCQA does not rate Medicare Supplemental plans, only Medicare Advantage plans.

Our plan is Accredited, but not all our submissions were used in the ratings. Why?

If your plan earned NCQA Accreditation using HEDIS data, only submissions used for Accreditation scoring are used in the ratings.

Our plan submitted HEDIS but is not listed in the ratings. Why?

Plan data submissions are excluded from the ratings if the submission is for a “special” product (e.g., CHIP, HOS only, SNP), an Exchange plan or outside the 50 states, DC, Guam, Puerto Rico or Virgin Islands.

Where should I send questions about ratings?

Direct all questions and requests about ratings to https://my.ncqa.org.

Can our plan get a list of the ratings from a previous year?

You can view the 2018–2019 Health Insurance Plan Ratings at healthinsuranceratings.ncqa.org. You can purchase an Excel version of the ratings in the NCQA Store.

Can our plan see its individual HEDIS scores or our competitor’s?

Individual HEDIS scores are available in the IDSS tool for the current data collection year (data collected during the year when the product is released).

The last three years of HEDIS and CAHPS scores are in NCQA’s Quality Compass for plans that publicly reported their results.