By Kathleen Doheny
WebMD Health News
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Reviewed by Michael W. Smith, MD
Sept. 22, 2016 -- Twenty-three insurance plans out of more than 1,000 have received the highest score of 5.0, according to new ratings released Thursday from the National Committee for Quality Assurance (NCQA).
Eighty-two plans received a 4.5, which is considered very good, says Andy Reynolds, an assistant vice president at the NCQA. The nonprofit looks at private, Medicaid, and Medicare plans for its ratings, which it has done annually since 2005. Private plans include both employer-based plans and those someone can buy on their own.
The Kaiser Foundation, University of Pittsburgh Medical Center, Capital District Physicians, Tufts, and Blue Cross Blue Shield of Massachusetts were among the 2016 standouts. Each company had more than one plan that received a 5 rating.
The 2016 NCQA Ratings
The ratings aim to help consumers make decisions about health insurance, which can be confusing and difficult to navigate. Other organizations like U.S. News & World Report, J.D. Power, and Medicare also rate insurance plans.
The ratings, available here, cover plans used by the majority of Americans and use a 0 to 5 rating system, Reynolds says.
The NCQA did not rate Marketplace plans offered under the Affordable Care Act, as those ratings are expected from the federal government. For those who are considering a Marketplace plan, Reynolds says, it's useful to look at the NCQA rating of the same plan offered as a private plan outside the Marketplace.
The ratings take three major categories into account:
- Consumer satisfaction: What patients say in satisfaction surveys, looking at things like how the companies handle claims and customer service.
- Prevention: How well the companies provide for this including checkups, tests, and other care that keeps people healthy, especially children.
- Treatment: How well a plan provides care for common and costly conditions, including heart disease, diabetes, and depression.
This year, 23 plans received a 5 rating, including 13 commercial plans, 8 Medicare plans, and 2 Medicaid plans. The commercial plans are:
- Blue Cross and Blue Shield of Massachusetts HMO Blue Inc. -- HMO/POS
- Capital District Physicians' Health Plan Inc. (CDPHP) -- HMO
- Capital District Physicians' Healthcare Network Inc. (CDPHN) -- HMO/POS
- Capital Health Plan Inc. -- HMO
- Johns Hopkins U.S. Family Health Plan -- HMO
- Kaiser Foundation Health Plan of the Mid-Atlantic States Inc. -- HMO
- Kaiser Foundation Health Plan Inc. - Northern California -- HMO
- Martin's Point U.S. Family Health Plan (ME) -- HMO
- Tufts Associated Health Maintenance Organization Inc. -- HMO/POS
- Tufts Benefit Administrators Inc. -- PPO
- UPMC Benefit Management Services Inc. -- HMO
- UPMC Health Coverage Inc. -- HMO
- UPMC Health Plan Inc. -- HMO
The Medicare plans are:
- Group Health Plan Inc. -- HMO
- Gundersen Health Plan Inc. -- HMO
- Kaiser Foundation Health Plan Inc. -- Southern California -- HMO
- Kaiser Foundation Health Plan of Georgia Inc. -- HMO
- Kaiser Foundation Health Plan of the Northwest Inc. -- HMO
- Kaiser Foundation Health Plan Inc. -- Hawaii -- HMO
- Kaiser Foundation Health Plan Inc. -- Northern California -- HMO
- Medical Associates Health Plan Inc. -- HMO
The Medicaid plans are:
- Jai Medical Systems Managed Care Organization Inc. -- HMO
- Kaiser Foundation Health Plan Inc. -- Hawaii -- HMO
The percentage of plans that received a good or very good rating fell slightly compared to last year, from 11.4% in 2015 to 10.4% this year, Reynolds says.
''The decline may be due to lower consumer satisfaction, even in plans that received high marks on prevention and treatment measures," Reynolds says.
Consumer satisfaction takes into account things like time to get an appointment and waiting time.
One commercial PPO plan received a 1.5: Hawaii Medical Service Association. And 13 Medicare plans got a 2 rating:
- Care Improvement Plus South Central Insurance Company -- PPO
- Cigna HealthCare of Indiana Inc. -- HMO
- Cuatro LLC dba Access Medicare New York -- HMO
- Easy Choice Health Plan Inc. -- HMO
- Elderplan Inc. -- HMO
- Group Health Incorporated -- PPO
- HAP Midwest Health Plan Inc. -- HMO
- HealthSpring Life and Health -- HMO
- Molina Healthcare of California Partner Plan Inc. -- HMO
- Molina Healthcare of Ohio Inc. -- HMO
- Sierra Health & Life -- PPO
- VNS CHOICE -- HMO
- WellCare Health Plans of New Jersey Inc. -- HMO
Two Medicaid programs received 1.5 ratings:
- Santa Clara County Health Authority -- HMO
- United Healthcare -- Texas -- HMO
In some cases, low ratings may mean a new plan that does not yet have enough data, says Elisa Yadao, a senior vice president at the Hawaii Medical Service Association, which received a 1.5 for one of its commercial plans.
"The 1.5 rating doesn't reflect our actual performance on this plan," Yadao says. "Next year, we will have that data to submit so we'll have a much more accurate rating, which we believe will fall in line with the 4.0 rating that our other commercial PPO plan received this year." One of the company's commercial plans received a 4 rating and another a 3.5.
How to Use the Ratings
In addition to looking at the overall rating, people should ''drill down'' into the areas that are important to them and see how the plan did in those measures, Reynolds says.
For example, a woman who is pregnant may want to know how the plan does on prenatal and postpartum care. Families with small children might be most interested in the measures of pediatric care and treatment.
If a health plan you are considering is not rated, but the same plan is highly rated in another state, it's an indication, but not a guarantee, that the one in your state performs well, too, Reynolds says. "It's never a direct correlation from state to state, but if a health plan is strong one place, its corporate culture and ways of working often contribute to comparable performance elsewhere," he says.
Objective information such as the NCQA ratings is helpful for consumers, says Glenn Melnick, PhD, Blue Cross of California Chair in Health Care Finance at the Schaeffer Center of the University of Southern California. He reviewed the new NCQA ratings.
"It's systematic, it's transparent, you know what they are measuring," says Melnick, who is also a resident consultant at RAND Corporation, a nonprofit research organization. "I congratulate them for collecting all this data and getting the systems in place."
But, he says, ''It's one tool'' and ''it's one among few."
Like other ratings, he says, it has limitations. "This is plan-level data," he says. "Plans don't deliver care; hospitals and doctors deliver care." So the results, he says, are an average. That means even if you pick a plan that has high marks, you may get the doctor who had poor marks, but was ''averaged out'' by the high-performing doctors.
That point becomes especially important, he says, if you are looking at a plan that has a ranking of 2, for instance. "It's much more likely you will end up with a provider who reflects this low score," he says.
"Some of the scores will also depend on the characteristics of people who join the plan," Melnick says. Plans that have many people who are frequent users of health care may have less patient satisfaction. The more people go to a doctor, he says, the more likely they are to encounter a frustrating situation and complain. Even so, Melnick says, plans with more frequent users may also provide more useful information.
Jamie Court, president of the advocacy organization Consumer Watchdog, says the ratings are most helpful for smaller health plans or regional ones because the major health plans typically offer the same quality across plans.
Clare Krusing, a spokesperson for industry group America's Health Insurance Plans, says while the ratings are helpful, consumers need to take other things into account when making a decision.
"It's more important that consumers take inventory of their monthly medical expenses and understand how much they want to pay when it comes to cost-sharing, out-of-pocket expenses and premiums," Krusing says.
The best plan, she says, depends on each individual's health and financial needs.
SOURCES: NCQA Health Insurance Plan Ratings 2016. Andy Reynolds, assistant vice president of marketing and communications, NCQARobert Saunders, PhD, assistant vice president of research and analysis, NCQA. Clare Krusing, spokesperson, America's Health Insurance Plans. Glenn Melnick, PhD, professor and Blue Cross of California Chair in Health Care Finance, Schaeffer Center, University of Southern California, Los Angeles. Jamie Court, president, Consumer Watchdog, Santa Monica, CA. Elisa Yadao, senior vice president of consumer experience, Hawaii Medical Service Association.
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