Glossary
A health plan may not be listed on this site for any of these reasons:
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Plans use many different names in the different areas they serve. If your plan is not listed,
be sure to review the list of additional names your health plan may use to see if it is included under a
different name on our report card. Additional plan names are listed under the plan name on the search results page.
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Some health plans choose not to participate in NCQA’s programs. Enrolling in an NCQA Accredited plan is one of
the best ways to ensure that you and your family will get the care, service and consideration you need,
when you need it. Contact your plan to see if they have applied for and received NCQA Accreditation.
If a plan chooses not to be reviewed by NCQA, you should ask: Why not?
If you receive health care coverage through your employer, talk with them about offering NCQA-accredited
plans. Health plans are more likely to focus on quality and seek accreditation if encouraged to do so by
health plan members and employers who make decisions about which plans to choose.
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Accreditation
Accreditation is a rigorous and comprehensive evaluation process through which NCQA assesses the quality of the key systems and processes that define health care organizations. Employers, consumers, regulators and health plans turn to NCQA Accreditation as the gold standard in evaluating health care quality. For many plans, Accreditation is voluntary. For others, state regulation requires NCQA Accreditation in whole or in part. View more information about Accreditation.
Accredited Product
The type of health plan offered by different health care organizations. NCQA uses the same standards and process to evaluate all types of plans (HMO, MCO, POS, PPO).
Accreditation Type
The Health Plan Report Card lists three types of NCQA Accreditation: Health Plan Accreditation, MCO Accreditation and PPO Accreditation. NCQA has discontinued its distinct MCO and PPO Accreditation Programs in favor of a single, consolidated accreditation program that uses a common set of standards and guidelines. The Health Plan Accreditation Program applies to HMO, MCO, POS and PPO plans.
CAHPS
A set of standardized surveys that measure patient satisfaction with the experience of care. CAHPS® is sponsored by the Agency for Health Care Research and Quality (AHRQ).
Distinction
Distinction is the designation given to health plans that have achieved one or more areas of Quality Plus.
HEDIS
HEDIS (Healthcare Effectiveness Data and Information Set) is a registered trademark of the National Committee for Quality Assurance. It is a tool used by more than 90 percent of America's health plans to measure performance on important areas of care and service. Altogether, HEDIS consists of 71 measurements across 8 areas of care. HEDIS measures address areas of care such as asthma medication use and controlling high blood pressure. View more information about HEDIS.
Managed Care
Managed care is a type of health care coverage that manages costs through its own network of physicians and pre-authorizes appointments with physician specialists.
Measure
A quantifiable measure to assess how well the organization carries out specific functions or processes.
Overall Accreditation Status
Overall Accreditation Status refers to the level of NCQA Accreditation a plan has received. NCQA Accreditation is a thorough and rigorous evaluation of a health plan for quality measurement and continuous quality improvement by NCQA.
Excellent
Overall Accreditation Status available to plans with MCO or Health Plan Accreditation. NCQA awards its highest accreditation status of Excellent to organizations with programs for service and clinical quality that meet or exceed rigorous requirements for consumer protection and quality improvement. HEDIS results are in the highest range of national performance.
Commendable
Overall Accreditation Status available to plans with MCO or Health Plan Accreditation. NCQA awards a status of Commendable to organizations with well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and quality improvement.
Accredited
Overall Accreditation Status available to plans with MCO or Health Plan Accreditation. NCQA awards an accreditation status of Accredited to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take further action to achieve a higher accreditation status.
Full
Overall Accreditation Status available to plans with PPO Accreditation. NCQA awards its highest accreditation status of Full Accreditation to organizations that meet or exceed NCQA standards and have excellent programs for quality improvement and consumer protection.
One-Year
Overall Accreditation Status available to plans with PPO Accreditation. NCQA awards a status of One-Year Accreditation status to organizations with well-established programs for quality improvement and consumer protection and which meet most NCQA standards. Organizations are given recommendations for improvement and are re-surveyed in one year to determine qualification for Full Accreditation.
Provisional
Overall Accreditation Status available to plans with MCO, PPO, or Health Plan Accreditation. NCQA awards a status of Provisional to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take significant action to achieve a higher accreditation status.
Denied
Overall Accreditation Status available to plans with MCO, PPO, or Health Plan Accreditation. NCQA denies Accreditation to organizations whose programs for service and clinical quality did not meet NCQA requirements during the Accreditation survey.
Appealed by Plan
NCQA designates Appealed by Plan to an organization when an accreditation status is under review at the request of that health plan.
In Process
Overall Accreditation Status available to plans with MCO, PPO, or Health Plan Accreditation. NCQA designates In Process to an organization when NCQA has surveyed the organization and is in the process of making a decision on accreditation status.
Revoked
Overall Accreditation Status available to plans with MCO, PPO, or Health Plan Accreditation. NCQA revokes Accreditation to an organization when circumstances have caused NCQA to withdraw Accreditation.
Scheduled
Overall Accreditation Status available to plans with MCO, PPO, or Health Plan Accreditation. NCQA designates Scheduled when a health plan is on NCQA's schedule for an Accreditation Survey.
Suspended
Overall Accreditation Status available to plans with MCO, PPO, or Health Plan Accreditation. NCQA suspends an organization when circumstances have caused NCQA to suspend Accreditation until it completes a thorough investigation and the health plan takes corrective action if needed.
Expired
Expired indicates a plan that was previously accredited has chosen not to undergo a survey to renew its status.
Under Review by NCQA
NCQA designates Under Review to an organization after NCQA has chosen to review the organization to assess the appropriateness of an existing accreditation status.
Merger Review in Process
NCQA designates Merger Review in Process to an organization that has informed NCQA that it is merging with another organization. NCQA will subsequently conduct a review of the merger to determine its impact on the organization's accreditation and certification status.
Plan Name
Plan name is the name of the organization that provides health care coverage to individuals and families.
Plan Type
The Plan Type refers to a specific plan that is designed to provide health care coverage to a certain population or group of people. NCQA divides plan type by Commercial, Medicare, and Medicaid.
Commercial
Commercial is a type of health care coverage paid for by employers or individual consumers.
Medicare
Medicare is 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
Medicaid is a federally-mandated and state-funded health care program for low income or disabled persons.
Copayment
A copayment is a fixed dollar amount that the patient must pay out-of-pocket for a particular health care service at the time of visit.
Deductible
The amount of money the insured patient must pay out-of-pocket before the insurance company must begin paying benefits. For example, if there is a $500 deductible, the insured patient must pay for the first $500 of health care expenses before the insurance company will begin paying claims.
Out-of-Pocket
The annual out-of-pocket maximum is the maximum amount a health plan will require the policy holder to contribute out-of-pocket towards the cost of care. This protects the insured from very high costs by capping the total amount spent on your health care each year. The policy holder must meet the annual deductible first before the annual out-of-pocket maximum applies. Once the deductible is met, copays will count towards the annual out-of-pocket maximum. Once the annual out-of-pocket maximum is reached, the policy holder should no longer be required to contribute towards the cost of care. In most cases, insurance covers 100 percent of the services required.
Premium
A premium is a periodic payment, often in installments, made on an insurance policy.
Star Ratings
Star ratings provide a view of plan performance in five categories. To calculate the star ratings, accreditation standards scores and HEDIS measure scores are allocated by category. The plan’s actual scores are divided by the total possible score. The resulting percentage determines the number of stars rewarded. For example, for MCO Accreditation, 90 percent and above equals four out of four stars and 80 percent to 89 percent equals three out of four stars. Plans with MCO and Health Plan Accreditation are eligible to receive up to 4 stars in each of the star rating categories; plans with PPO Accreditation are eligible to receive up to 3 stars in the Access & Service and Qualified Providers categories.
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. Plans with MCO and Health Plan Accreditation may receive up to 4 stars; plans with PPO Accreditation may receive up to 3 stars.
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. Plans with MCO and Health Plan Accreditation may receive up to 4 stars; plans with PPO Accreditation may receive up to 3 stars.
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. Plans with MCO and Health Plan Accreditation may receive up to 4 stars; this category does not apply to plans with PPO Accreditation.
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. Plans with MCO and Health Plan Accreditation may receive up to 4 stars; this category does not apply to plans with PPO Accreditation.
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. Plans with MCO and Health Plan Accreditation may receive up to 4 stars; this category does not apply to plans with PPO Accreditation.
Quality Plus
Quality Plus is an NCQA program that provides consumers and employers with information on how well plans communicate with members, leverage technology, reward quality, and promote wellness and disease management. In 2008, NCQA integrated two areas of Quality Plus – Member Connections and Care Management and Health Improvement – into Health Plan Accreditation. Plans that have earned Health Plan Accreditation are given credit for these two Distinction areas. NCQA also converted Physician and Hospital Quality (PHQ), the third area of Quality Plus, to a certification program and closed the Quality Plus Distinction PHQ program to new applications.
Member Connections
Member Connections standards are designed to measure how health plans connect members with important information such as their health status, the resources provided by their health plan, their care options, and the costs of different services and prescription drugs. Member Connections standards have been included in the MCO Accreditation and PPO Accreditation standards since 2007 and Health Plan Accreditation since 2008. Some plans have voluntarily achieved distinction in this area prior to its inclusion in accreditation.
Care Management and Health Improvement
Care Management and Health Improvement standards measure, among health plans, the promotion of wellness and prevention as well as the identification and management of members with chronic illnesses or complex conditions. Care Management and Health Improvement standards have been included in MCO Accreditation since 2007 and Health Plan Accreditation since 2008. Some plans have voluntarily achieved distinction in this area prior to its inclusion in accreditation.
Physician and Hospital Quality
Physician and Hospital Quality standards evaluate how health plans measure the quality and cost of care provided by network physicians and hospitals. Physician and Hospital Quality is a voluntary distinction program. Distinction in Physician and Hospital Quality displayed on this report card refers to plans’ performance on the 2006 version of the Physician and Hospital Quality standards only, and after March 2, 2008, NCQA will no longer accept applications from health plans for PHQ distinction.
Standard
A standard is a basis for comparison or a reference point against which organizations can be evaluated. NCQA standards are statements about acceptable performance.
