To provide consumers with useful, comparable information about health insurance carriers, the federal government (Centers for Medicare & Medicaid Services, or CMS) conducts, calculates, and publishes annual quality measures across all insurance carriers that offer health plans on the Healthcare Exchange.
The plan quality ratings and enrollee survey results are calculated by the federal government, using data provided by health plans in the prior year. All health plan ratings are calculated the same way with the same information sources across all providers.
CMS scores qualified health plans (QHPs) offered through the Exchanges using the Quality Rating System (QRS) based on third-party validated clinical measure data and QHP Enrollee Survey responses. CMS calculates QRS ratings yearly on a 5-star scale. QHP issuers work with Human & Health Services (HHS)- approved survey vendors that independently conduct the survey each year. QRS ratings and QHP Enrollee Survey results may change from year to year.
Overall Rating
The overall quality rating is displayed from 1 to 5 stars (5 is highest) and is calculated based on three components - medical care, member experience, and health plan administration. CMS assigns a weight to each component to calculate the overall rating.
| Component | Description | Data Source | Weighting |
|---|---|---|---|
| Medical Care | How well the plan’s network providers (doctors, pharmacies, etc.) manage member health care | Clinical | 2/3(66.7%) |
| Member Experience | How satisfied members are with the plan’s network of providers, as well as ease & speed of getting appointments & services | Survey | 1/6(16.7%) |
| Plan Administration | How well the plan is run, including customer service, access to needed information, and the ordering of appropriate tests & treatment | Clinical & Survey | 1/6(16.7%) |
Medical Care
Medical care describes how well the plan’s network providers (doctors, pharmacies, etc.) manage member care and is calculated from third-party validated clinical measure data. CMS puts more emphasis on medical care because these measures are aligned to CMS’ mission to improve overall population health, so plans that score well in its clinical measures end up having higher star ratings.
Below are examples of clinical measures being evaluated. Please note that this list is not exhaustive and these measures may change each year.
Member Experience
Member Experience describes how satisfied members are with their healthcare & doctors, as well as the speed & ease of getting appointments & services.
Member Experience is calculated from independently conducted & audited survey results on the below questions, which are then aggregated to develop component scores.
↓ Access to Care (in-person, telephone or video appointments are included).
o When you needed care right away, in an emergency room, doctor’s office, or clinic, how often did you get care as soon as you needed?
o How often did you get an appointment for a check-up or routine care at a doctor’s office or clinic as soon as you needed?
o How often was it easy to get the care, tests or treatment you needed?
o How often did you get an appointment to see a specialist as soon as you needed?
↓ Care Coordination
o When you visited your personal doctor for a scheduled appointment, how often did he or she have your medical records or other information about your care?
o When your personal doctor ordered a blood test, x-ray, or other test for you, how often did someone from your personal doctor’s office follow up to give you those results?
o When your personal doctor ordered a blood test, x-ray or other test for you, how often did you get those results as soon as you needed them?
o How often did your personal doctor seem informed and up-to-date about the care you got from specialists?
o How often did you and your personal doctor talk about all the prescriptions you were taking?
o How often did you get the help that you needed from your personal doctor’s office to manage care among these different providers & services?
↓ Doctor & Care
o Rating of Health Care: Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care? Include in-person, telephone or video appointments.
o Rating of Personal Doctor: Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor?
o Rating of Specialist: We want to know your rating of the specialist you saw the most often in the last 6 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate the specialist?
Health Plan Administration
Health plan administration describes how well the plan is run, including customer service, access to needed information, and controls to drive appropriate treatment & tests measured by clinical measure data. Below are examples of survey questions that are incorporated into this measure (please note these are not exhaustive and could change each year).
o Rating of Health Plan: Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?
o Plan Administration
o How often did your health plan’s customer service give you the information or help you needed?
o How often did your health plan’s customer service staff treat you with courtesy and respect?
o How often did the time that you waited to talk to your health plan’s customer service staff take longer than you expected?
o How often were the forms from your health plan easy to fill out?
o How often did the health plan explain the purpose of the form before you filled it out?
o Access to Information
o How often did the written materials or the Internet provide the information you needed about how your health plan works?
o How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment before you got it?
o How often were you able to find out from your health plan how much you would have to pay for specific prescription medicines?
How come some insurance carriers are not rated?
Some insurers do not have enough members or claims to appropriately calculate the rating for a measure. For example, if an insurer doesn’t have a lot of smokers enrolled in their plan, they will not receive a ton of responses for offering medical assistance with smoking & tobacco use cessation. Because of this dynamic, the government sets up required denominator sizes for each measure, and if an insurer doesn’t meet that denominator, they get an “N/A” or “Not Applicable” for that score. An “N/A” does not mean that the plan is bad or good, it just means that it couldn’t be measured appropriately.
