Insurance Terms

Fee-for-service

A traditional method of paying for medical services. A doctor charges a fee for each service provided, and the insurer or patient pay all or part of that fee.

HEDIS^® (Health Plan Employer Data and Information Set)

HEDIS is NCQA's tool used by health plans to collect data about the quality of care and service they provide. HEDIS consists of a set of performance measures that tell how well health plans perform in key areas: quality of care, access to care and member satisfaction with the health plan and doctors. HEDIS requires health plans to collect data in a standardized way so that comparisons are fair and valid. Health plans can arrange to have their HEDIS results verified by an independent auditor.

Health Plan

NCQA defines health plan to include HMO, POS and PPO plans.

Managed Care Organization

A general term for health plans that provide health care in return for pre-set monthly payments and coordinate care through a defined network of primary care physicians and hospitals.

Product Line

Refers to the population that the health plan covers:

Commercial: Health care coverage paid for by employers or individual consumers.

Medicare: The federal government's health care program for all persons over the age of 65 and for younger persons who have disabilities and cannot work.

Medicaid: A state-funded health care program for low income or disabled persons.

Product

Refers to the type of health plan:

HMO (health maintenance organization): HMOs are the oldest form of managed care plan. HMOs offer members a range of health benefits for a set monthly fee. HMOs will give you a list of doctors from which to choose a primary care doctor. This doctor coordinates your care, which means that generally you must contact him or her to be referred to a specialist.

With some HMOs, you will pay nothing when you visit doctors. With other HMOs there may be a copayment, like $5 or $10, for various services. If you belong to an HMO, the plan only covers the cost of charges for doctors in that HMO. If you go outside the HMO, you will pay the bill. This is not the case with point-of-service plans.

MBHO (managed behavioral healthcare organization): A system of behavioral healthcare delivery that manages quality, utilization and cost of services, and which measures performance in the area of mental and substance abuse disorders.

POS (point of service): Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you will have to pay coinsurance.

PPO (preferred provider organization): A PPO is a form of managed care that has contracts with doctors, hospitals and other providers of care who offer medical services to enrollees on a fee-for-service basis. As a result, you may use any provider within or outside of the PPO network, but have a financial incentive to stay within the network. If you go to a doctor within the PPO network, you will pay a copayment (a set amount you pay for certain services-say $10 for a doctor or $5 for a prescription). If you choose to go outside the network, you will have to meet the deductible and pay coinsurance based on higher charges.

Categories for Star Ratings

Access and Service

NCQA evaluates how well the health plan provides its members with access to needed care and with good customer service. For example: Are there enough primary care doctors and specialists to serve the number of people in the plan? Do patients report problems getting needed care? How well does the health plan follow up on grievances? To evaluate these activities, NCQA reviews appeals and health plan denials records, interviews health plan staff and grades the results from consumer surveys. View specific requirements a plan has to meet to be accredited by NCQA in the Access and Service category.

Qualified Providers

NCQA evaluates health plan activities that ensure each doctor is licensed and trained to practice medicine and that the health plan's members are happy with their doctors. For example: Does the health plan check whether physicians have had sanctions or lawsuits against them? How do health plan members rate their personal doctors or nurses? To evaluate these activities, NCQA uses records of doctors' credentials, interviews health plan staff and grades the results from consumer surveys. View specific requirements a plan has to meet to be accredited by NCQA in the Qualified Providers category.

Staying Healthy

NCQA evaluates health plan activities that help people maintain good health and avoid illness. For example: Does the health plan give its doctors guidelines about how to provide appropriate preventive health services? Are members receiving tests and screenings as appropriate? To evaluate these activities, NCQA reviews health plan records, grades independently verified clinical data and reviews materials sent to members. View specific requirements a plan has to meet to be accredited by NCQA in the Staying Healthy category.

Getting Better

NCQA evaluates health plan activities that help people recover from illness. For example: How does the health plan evaluate new medical procedures, drugs and devices to ensure that patients have access to the most up-to-date care? Do doctors in the health plan advise smokers to quit? To evaluate these activities, NCQA reviews health plan records and interviews health plan staff. View specific requirements a plan has to meet to be accredited by NCQA in the Getting Better category.

Living with Illness

NCQA evaluates health plan activities that help people manage chronic illness. For example: Does the plan have programs in place to assist patients in managing chronic conditions like asthma? Do diabetics, who are at risk for blindness, receive eye exams as needed? NCQA grades independently verified clinical data and interviews health plan staff. View specific requirements a plan has to meet to be accredited by NCQA in the Living with Illness category.

Star Ratings

For each organization included in NCQA’s various report cards, a certain number of stars appear in each category of standards and measures against which that organization was evaluated. These stars reflect how well an organization performed against the standards and/or measures in that category. For HMO/POS plans, 4 stars indicates the highest level of performance in a category. For PPO Plans, 3 stars indicates the highest level of performance. Health plans for which NCQA Denied, Suspended, or Revoked accreditation are not eligible to receive stars for any of the Report Card categories.

Accreditation Outcomes

Excellent (for HMOs and POS plans)

NCQA's highest accreditation outcome is granted only to those plans that demonstrate levels of service and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement. Plans earning this accreditation level must also achieve HEDIS^® results that are in the highest range of national or regional performance.

Full (for PPOs)

NCQA 's highest accreditation outcome for PPOs is granted to those plans that have excellent programs for quality improvement and consumer protection and that meets or exceeds NCQA's standards. Full accreditation is effective for a three-year period.

Commendable (for HMOs and POS plans)

This accreditation outcome is awarded to plans that demonstrate levels of service and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement.

One-Year (for PPOs)

The PPO plan has well-established programs for quality improvement and consumer protection and meets most NCQA standards. NCQA has given the PPO a list of recommendations and will review the organization again after a year to determine if it qualifies for Full Accreditation.

Accredited

Health plans that earn the Accredited outcome must meet most of NCQA's basic requirements for consumer protection and quality improvement.

Provisional

Provisional accreditation indicates that a health plan's service and clinical quality meet some, but not all of NCQA's basic requirements for consumer protection and quality improvement.

Denied

Denied is an indication that a health plan did not meet NCQA's requirements during its review.

Appealed by Plan

Indicates an initial accreditation outcome is under review at the request of the health plan.

In Process

Indicates NCQA has reviewed the health plan for the first time and is in the process of making a decision on the accreditation outcome.

Revoked

Indicates serious circumstances have caused NCQA to withdraw accreditation of the health plan.

Scheduled

Indicates the health plan is on NCQA's schedule for an initial accreditation review. Some of the plans listed as “Scheduled” may be accredited under NCQA’s New Health Plan Accreditation program.

Suspended

Indicates circumstances have caused NCQA to withdraw accreditation until NCQA completes a thorough investigation, and the plan takes corrective action.

Under Review by NCQA

Indicates NCQA has chosen to re-review the health plan in order to assess the appropriateness of an existing accreditation outcome.

Quality Plus

Quality Plus is NCQA's initiative to update its MCO and PPO accreditation programs in important new areas. Quality Plus is a voluntary program. Plans can opt to achieve distinction in selected Quality Plus content areas in addition to their accreditation. The Quality Plus content areas provide consumers and employers with invaluable new information about how well plans communicate with members, leverage technology, reward quality and promote wellness and disease management.

Member Connections

The Member Connections standards are designed to encourage health plans to adopt innovative practices—such as making more information Web-accessible—that help "connect" members with important information about their health, resources provided by their health plan, their care options and even the costs of different services and drugs. The standards also assess how effectively an organization helps members understand benefits, self-manage certain medical conditions and check the status of their claims. View specific requirements a plan has to meet to be accredited by NCQA in this category.

Care Management and Health Improvement

The Care Management and Health Improvement standards distinguish health plans that effectively promote wellness and prevention, and identify and manage members with chronic illnesses or complex conditions. Patients with complex or multiple illnesses often require particularly individualized or intensive treatment. The standards ask not only whether programs— known as "case management" programs—exist, but also how effectively members who might benefit are referred to the programs. The standards also assess how plans measure the impact of case management using, for example, rates of hospital readmissions and emergency room visits. View specific requirements a plan has to meet to receive distinction from NCQA in this category.

Physician and Hospital Quality

The Physician and Hospital Quality standards evaluate how health plans measure the quality and cost of care provided by network physicians and hospitals. Health plans seeking distinction in Physician and Hospital Quality must demonstrate that they measure the quality and cost of in-network hospitals and physicians, and that, whenever possible, they act on information about cost in conjunction with information about quality. View specific requirements a plan has to meet to receive distinction from NCQA in this category.

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