To evaluate how the health plan takes care of its members who are chronically sick, NCQA grades independently verified clinical data, reviews health plan records and interviews health plan staff. NCQA looks for:

• active efforts to improve the health of plan members with chronic conditions.

• the percentage of plan members with diabetes who received an eye exams to detect blindness, a complication resulting from diabetes, early.

• the percentage of plan members, hospitalized for a mental illness, who were seen by a provider within 7 days of hospital discharge.

• the percentage of plan members who had a heart attack and received beta blockers, a medication that helps prevent future heart attacks.

• the percentage of plan members who were diagnosed with a new episode of depression, treated with antidepressant medication and had subsequent follow-up visits, to ensure recovery through proper dosage.

• The percentage of plan members treated for an acute cardiovascular event or diagnosed with ischemic vascular disease (IVD), who received a follow-up cholesterol screening in the next year.

• policies that ensure that the drugs the health plan covers are safe and effective and that plans give members the right to appeal for coverage of drugs not normally covered.

• a well-defined program for improving the quality of clinical care and service provided to plan members.

• individuals in the health plan responsible for overseeing quality improvement programs.

• distribution of guidelines that assist doctors with providing the right care to plan members with chronic conditions.

• evidence of monitoring the quality of care provided to plan members with specific chronic conditions.

• evidence that the health plan takes action to improve the quality of care provided to plan members with specific chronic conditions.

• actual improvements that the plan has made in care and service.

welcome | create report card | using results | definitions | methods | participation/statistics | feedback | top

©National Committee for Quality Assurance - 1100 13th Street, NW, Suite 1000, Washington, DC 20005 - (202) 955-3500
contact Webmaster@ncqa.org