To evaluate how the health plan helps its members to stay healthy, NCQA reviews health plan records, interviews health plan staff and grades independently verified clinical data and results from consumer surveys conducted by independent survey organizations. NCQA looks for:

• the presence of guidelines for doctors about the need to provide immunizations and screening tests to plan members.

• effective communications that make doctors in the plan aware of the guidelines.

• effective communications that make plan members aware of what they can do to reduce illness, disease and accidents.

• the percentage of children under the age of two who have received recommended immunizations to prevent childhood diseases.

• the percentage of children who, by the age of 13, have received recommended immunizations for the continued protection against childhood diseases.

• the percentage of Medicare members over the age of 65 who received an influenza vaccination to prevent the flu (only for health plans serving Medicare beneficiaries).

• the percentage of women ages 52-69 who received a mammogram with the past two years to detect breast cancer early.

• the percentage of adult women who received a pap smear within the past three years to detect cervical cancer early.

• the percentage of pregnant women who received their first prenatal care visit during the first three months of pregnancy.

• the percentage of new mothers who received a check-up within eight weeks after delivery.

• 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.

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

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