What Is the National Committee for Quality Assurance (NCQA)?
The National Committee for Quality Assurance (NCQA) is an independent nonprofit organization that assesses health insurance plans, providers, practices, and other health care organizations for quality and performance. It accredits health insurance plans and provides report cards for them that contain star ratings.
You can use NCQA Health Plan Report Cards and star ratings when shopping for health insurance or a Medicare Advantage plan. Among other things, these ratings reflect how patients feel about how easy it has been to get care through a particular plan and how satisfied they are with the care they received, the health care providers associated with the plan, and the policy itself.
The ratings also reflect data that the NCQA gathers on access to care, how well plans help members understand and use their benefits, how well they protect patient privacy, and the quality of medical care patients receive. Quality measures address wellness and prevention, chronic disease management, and how well resources are used.
Key Takeaways
- The NCQA is a nonprofit organization that provides accreditation and data-based reporting on health insurance companies.
- NCQA Health Plan Report Cards allow you to see star ratings of various plans, including private health insurance and Medicare Advantage plans.
- Report cards list ratings in response to surveys on various measures such as patient experiences and care delivery, including for select chronic diseases.
- NCQA Health Plan Ratings differ from CMS Star Ratings, although both rely on similar data categories.
How Do NCQA Ratings Work?
The NCQA's Report Card tool helps consumers identify high-performing organizations of different types. For health insurance plans specifically, the tool lists the following types of plans:
- Commercial plans sold to employers and individuals
- Medicare Advantage plans
- Medicaid plans
- Exchange health plans
Note that the NCQA does not rate Affordable Care Act Marketplace plans or Medicare supplement insurance plans. However, you can still use the tool to see if an Exchange plan is accredited.
Ratings of 0–5 stars are based on overall measurements of an insurer’s patient care quality and patient satisfaction (their combined HEDIS and CAHPS scores), alongside accreditation—as we’ll explain a little further below.
Note
NCQA report cards also recognize health care clinicians, practices, and organizations that meet NCQA standards for offering high-quality, patient-centered care.
You can use the tool to search by:
- Name
- Star rating
- Accreditation status
- Plan type
- Product type (such as PPOs or HMOs: preferred plan organizations and health maintenance organizations, respectively)
- States serviced
Each report card offers basic facts, such as the insurer's website and number of enrollees. It also provides details and ratings related to the patient experience, preventive care, and treatments.
Making these ratings public is intended to improve outcomes by putting pressure on providers and health insurance plans.
“Quality measurement and contracting based on quality measures have been shown to motivate providers to increase screening and immunizations, and to pursue testing and treatment of chronic diseases such as high blood pressure, diabetes, and depression,” said Dr. Eric Schneider, who leads NCQA’s measurement, research, and contracting agenda.
HEDIS Measures
The NCQA developed and publishes the Healthcare Effectiveness Data and Information Set (HEDIS) measurements every year. It uses HEDIS measurements to evaluate the delivery of preventive services and recommended care for certain conditions.
Within the report card, ratings compare plans’ delivery of specific types of care based on survey data. The treatments assessed include those for these common chronic and acute conditions:
- Respiratory distress
- Diabetes
- Heart disease
- Behavioral health (mental health and substance abuse)
Other assessments have more to do with efficient health care utilization and ongoing public health crises such as opioid overuse. Assessments also review an insurer’s ability to provide older patient care (such as managing fall risks) and preventive services.
“In general, each measure indicates the percent of the plan members who should have received care and whether they received it or not,” Schneider said.
Note
More than 90% of U.S. health plans use HEDIS to measure performance on care and service.
CAHPS Scores
The U.S. government’s Agency for Healthcare Research and Quality (AHRQ) developed the Consumer Assessment of Healthcare Providers and Systems (CAHPS) in 1995. CAHPS data focuses on the member or patient experience.
“CAHPS is a standardized survey of plan members about their experience with the health plan,” Schneider said. “Higher scores on CAHPS items indicate that the plan provides a better experience.”
Overall, the NCQA report card uses CAHPS survey data to share member experiences in terms of:
- How easy it was to get care
- Satisfaction with primary care providers, specialists, and care coordination
- Satisfaction with the health plan and rating of care
What Is NCQA Accreditation?
The NCQA's Accreditation process evaluates whether a plan meets a set of standards that indicate its capability to deliver high-quality service to members, Schneider said.
Accreditation is based on HEDIS, CAHPS, and NCQA standards data on how health plans should be organized and operated. The NCQA publicly reports accreditation results to empower informed consumer decisions and ensure accountability within the health care industry.
Accreditation provides plans with a proven incentive for improvement. The NCQA says accredited Medicare Advantage plans perform better than other plans in terms of prevention, treatment, and member experience.
How Can Consumers Use NCQA Information?
NCQA report card information may best fit those shopping for employer-sponsored benefit plans or Medicare Advantage plans during open enrollment.
You can use the tool to search by state and star rating to find your state’s top-rated plans, or you can search by state and type to compare ratings for Medicare or other types of plans.
Unfortunately for ACA customers, there are no ratings for Exchange plans—only accreditation results. However, accreditation does indicate whether the plan meets the NCQA’s standards.
You can use the NCQA’s Report Card to get a sense of an insurance plan’s overall patient satisfaction and how well the plan is providing care to members. For example, you can review members' responses on how easily they get appointments and access to preventive care, tests, and treatment.
If you have a condition such as diabetes, you can examine the NCQA Report Card data to reveal a plan’s success on various measures, which may indicate how well that plan can manage your diabetes.
For example, the report card rates whether diabetic patients on the plan have well-managed blood pressure and blood sugar. It can also tell you how well a plan’s patients with diabetes receive and stay on statin therapy.
Schneider said plans with more stars perform better on the measures assessed. However, consumers must still decide whether specific measures are relevant to their health conditions.
NCQA Health Plan Ratings vs. Medicare Star Ratings
The publishes the Medicare Advantage (Medicare Part C) and Medicare Part D star ratings annually. These ratings are viewable when you search for a plan on Medicare.gov.
Both NCQA ratings for health plans and Medicare star ratings use a star scale for ratings. They offer feedback on health plans and can guide consumers in choosing a plan. Both use similar measurements, such as HEDIS and CAHPS, to assess plans, with measurements overlapping in some cases.
However, the two programs score differently, and Medicare star ratings more closely evaluate Medicare Advantage and Part D plans. For example, Medicare star ratings include survey responses regarding a Medicare Advantage plan’s accuracy in drug pricing and members' experiences regarding the drug plan.
In addition, the NCQA evaluates and accredits a variety of commercial and Medicaid plans, while the CMS only evaluates Medicare Advantage (Part C) and Part D plans.
History and Reach Today
The NCQA was founded in 1990 by current president Margaret E. O’Kane and has more than 400 full-time employees. NCQA is the most widely recognized health care accreditation program in the United States, with more than 1,200 health plans accredited. NCQA Health Plan Accreditation is required or used by 42 states, and 76% of all insured Americans have health plans accredited by NCQA.
Frequently Asked Questions (FAQs)
What Are NCQA Standards?
NCQA standards are a framework of evidence-based best practices. These standards can help plans improve if there’s a gap between the plan’s current offerings and the NCQA standards. The standards also align with many state requirements and with what employers seek in plans, according to the NCQA. A few standards include:
- Population health management
- Practitioner network and access to care
- Members’ rights and responsibilities
Plans are held up to standards that evolve based on medical evidence.
What’s the Difference Between NCQA Ratings and Medicare Star Ratings?
The primary difference between them is that Medicare Star Ratings only rate Medicare plans, including Advantage and Part D plans. NCQA also rates Medicaid and employer-provided commercial insurance. They also have different scoring weights and subcategories of assessments.
What Type of Organization is NCQA?
NCQA is a nonprofit organization that uses data and measurement to improve health care quality. It also offers the seal of accreditation to health plans meeting NCQA standards, and assesses plans annually for member satisfaction and health service delivery.
The Bottom Line
The NCQA awards accreditation as “a sign that organizations deliver high-quality care and have strong member protections.” NCQA data can help you research plans when it’s time for open enrollment at work or if you’re signing up for Medicare.
New ratings are released electronically on or around Sept. 15, in time for consumers to use the information when they choose health plans during traditional open enrollment season, which occurs in late autumn and early winter.
However, much of NCQA’s work on your behalf is also done behind the scenes. At least one insurance company notes it has a team that works year-round to meet NCQA’s standards and improve member health. After receiving the annual audit, the plan addresses gaps and areas for improvement, such as ensuring more members get their flu shots.
