Glossary

General Terms | Commercial Plan Terms | HMOs Plan Terms | Medicaid Plan Terms

General Terms

Rank: Based on score. Commercial, HMOs, and Medicaid health plans are ranked separately.

Score: The highest possible score is 100, including up to 15 points for NCQA accreditation. Plans are judged by performance relative to other plans on consumer satisfaction, preventive care, and treatment. Fifty measures were evaluated for commercial plans, 28 for HMOs plans, and 35 for Medicaid plans.

State: Where the plan operates.

Type: HMO—health maintenance organization, in which a primary-care physician provides routine care and a network of specialists provides other care. Members pay out of pocket for care received outside the network. POS—point-of-service plan, in which the plan pays some of the cost of out-of-network care.

NCQA accreditation: The National Committee for Quality Assurance is the major accrediting and standards-setting body for managed-care organizations.

I: Insufficient data to determine a score.

NA: Not applicable. A plan did not report data for a particular measure because the measure describes a benefit that isn't offered or because the number of members to whom the measure applies is too small.

NR: Not reported. A plan did not calculate a measure or calculated it but chose not to report it.

Commercial Plan Terms

Performance was measured relative to other plans, not to an independent standard.

Consumer assessment

Getting care
Getting care needed: Proportion of surveyed members who said it was easy to get appointments, preventive care, tests, and treatment.

Getting care needed quickly: Proportion of surveyed members who said it was easy to get appointments, preventive care, tests, and treatment promptly.

Satisfaction with physicians
How well doctors communicate: Proportion of surveyed members who gave plan's doctors a high rating in communications skills.

High rating of personal doctor: Proportion of surveyed members who gave their personal physician a high overall rating.

High rating of specialists: Proportion of surveyed members who gave plan's specialists a high overall rating.

High rating of care received: Proportion of surveyed members who gave the healthcare they received a high overall rating.

Satisfaction with health plan services
Claims processing: Proportion of surveyed members satisfied with how their claims were handled.

High rating of plan services: Proportion of surveyed members who gave the overall level of plan services a high rating.

Prevention

Children and adolescents
Well-child visits (birth to 15 months): Proportion of children who had at least six well-child visits from birth to 15 months old.

Well-child visits (3-6 years old): Proportion of children ages 3, 4, 5, and 6 who had at least one well-child visit.

Access for children (7-11 years old): Proportion of children ages 7 to 11 who had a visit with a primary-care physician.

Adolescent well-care visits: Proportion of members ages 12 to 21 who had at least one comprehensive well-care visit.

Immunizing children and adolescents
All immunizations at age 2: Proportion of children who got all recommended immunizations by their second birthday.

All immunizations at age 13: Proportion of adolescents who got all recommended follow-up immunizations by their 13th birthday.

Women's reproductive health
Timeliness of prenatal checkups: Proportion of women who gave birth and had a prenatal visit during the first trimester.

Postpartum care: Proportion of women who had a postpartum visit between three and eight weeks after delivery.

Cancer screening
Breast cancer screening: Proportion of women ages 40 to 69 who had a mammogram.

Cervical cancer screening: Proportion of women ages 21 to 64 who had a Pap test.

Colorectal cancer screening: Proportion of members ages 50 to 80 who were screened for colorectal cancer.

Other preventive services
Chlamydia screening (16-25 years old): Proportion of women ages 16 to 25 who were tested for chlamydia.

Treatment

Asthma
Medicate appropriately (5-9 years old): Proportion of asthmatic children ages 5 to 9 who were appropriately prescribed medication.

Medicate appropriately (10-17 years old): Proportion of asthmatic children ages 10 to 17 who were appropriately prescribed medication.

Medicate appropriately (18-56 years old): Proportion of asthmatic adults ages 18 to 56 who were appropriately prescribed medication.

Diabetes
Retinal eye exams: Proportion of members ages 18 to 75 with type 1 or 2 diabetes who had a retinal exam.

Glucose testing: Proportion of members ages 18 to 75 with type 1 or 2 diabetes who had a blood glucose test.

Glucose control: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose blood glucose level was maintained below 9 percent.

LDL cholesterol screening: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose level of LDL (bad) cholesterol was checked.

LDL cholesterol control: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose LDL cholesterol level was maintained below 100 milligrams/deciliter.

Monitoring kidney disease: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose kidney function was checked.

Heart disease
Giving beta blocker after heart attack: Proportion of members ages 35 and above who had a heart attack and received a beta blocker within seven days of discharge.

Staying on beta blocker after heart attack: Proportion of members ages 35 and above who had a heart attack and received treatment with a beta blocker for at least six months after discharge.

Controlling high blood pressure: Proportion of members ages 18 to 85 who were diagnosed with hypertension and whose most recent blood pressure reading was below 140/90.

Advising smokers to quit: Proportion of smoking members ages 18 and above who were advised by a practitioner to stop.

Discussing stop-smoking strategies: Proportion of smoking members ages 18 and above who discussed methods or strategies for quitting with a practitioner.

Discussing stop-smoking medications: Proportion of smoking members ages 18 and above who discussed medications for quitting.

LDL cholesterol screening: Proportion of members ages 18 to 75 with heart disease whose LDL (bad) cholesterol level was checked.

LDL cholesterol control: Proportion of members ages 18 to 75 with heart disease whose LDL cholesterol level was maintained below 100 milligrams/deciliter.

Mental and behavioral health
Depression—appropriate follow-up after diagnosis: Proportion of members ages 18 and above who were newly diagnosed with depression, prescribed medication, and had at least three visits with a practitioner during the next 12 weeks.

Depression—adhering to medication for 12 weeks: Proportion of members ages 18 and above who were newly diagnosed with depression, prescribed medication, and remained on the drug during the next 12 weeks.

Depression—adhering to medication for six months: Proportion of members ages 18 and above who were newly diagnosed with depression, prescribed medication, and remained on the drug for at least six months.

Follow-up after hospitalization for mental illness: Proportion of members ages 6 and above who were hospitalized because of mental illness and were seen for follow-up care within a week and again within a month of discharge.

Alcohol or drug dependence treatment initiated: Proportion of members ages 13 and above who were diagnosed with alcohol or drug dependence and treated as inpatients or outpatients.

Alcohol or drug dependence treated for 30 days: Proportion of members ages 13 and above who were diagnosed with alcohol or drug dependence and received at least two related services within 30 days of the initial treatment.

Follow-up after ADHD diagnosis: Proportion of children ages 6 to 12 initially diagnosed with attention deficit hyperactivity disorder who were prescribed medication and had a visit with a practitioner within 30 days.

Other treatment measures
Medication for rheumatoid arthritis: Proportion of members ages 18 and above who were diagnosed with rheumatoid arthritis and were prescribed an appropriate drug.

Monitoring of key long-term medications: Proportion of members ages 18 and above who received a six-month supply of any of the following drugs and were being clinically monitored: ACE inhibitors, angiotensin receptor blockers (ARBs), digoxin, diuretics, or anticonvulsants.

Spirometry testing for COPD: Proportion of members ages 40 and above whose diagnosis of chronic obstructive pulmonary disease was confirmed with a spirometry test.

Appropriate antibiotic use, children with URI: Proportion of children from 3 months to 18 years old who were not prescribed an antibiotic for up to three days after being diagnosed with a common cold.

Appropriate testing and care, children with pharyngitis: Proportion of children ages 2 to 18 who were diagnosed with a sore throat, prescribed an antibiotic, and tested for strep.

Appropriate antibiotic use, adults with acute bronchitis: Proportion of adults ages 18 to 64 who were not prescribed an antibiotic within three days of a diagnosis of acute bronchitis.

Medicare Terms

Performance was measured relative to other plans, not to an independent standard.

Prevention
Breast cancer screening: Proportion of women ages 65 to 69 who had a mammogram.

Colorectal cancer screening: Proportion of members ages 65 to 80 who were screened for colorectal cancer.

Glaucoma screening: Proportion of members screened for glaucoma.

Evaluating physical health status: Proportion of members whose physical health status was assessed at the beginning and end of a two-year period.

Evaluating mental health status: Proportion of members whose mental health status was assessed at the beginning and end of a two-year period.

Treatment

Diabetes
Retinal eye exams: Proportion of members ages 65 to 75 with type 1 or 2 diabetes who had a retinal exam.

Glucose testing: Proportion of members ages 65 to 75 with type 1 or 2 diabetes who had a blood glucose test.

Glucose control: Proportion of members ages 65 to 75 with type 1 or 2 diabetes whose blood glucose level was maintained below 9 percent.

LDL cholesterol screening: Proportion of members ages 65 to 75 with type 1 or 2 diabetes whose level of LDL (bad) cholesterol was checked.

LDL cholesterol control: Proportion of members ages 65 to 75 with type 1 or 2 diabetes whose LDL (bad) cholesterol level was maintained below 100 milligrams/deciliter.

Monitoring kidney disease: Proportion of members ages 65 to 75 with type 1 or 2 diabetes whose kidney function was checked.

Heart disease
Giving beta blocker after heart attack: Proportion of members who had a heart attack and received a beta blocker within seven days of discharge.

Staying on beta blocker after heart attack: Proportion of members who had a heart attack and received treatment with a beta blocker for at least six months after discharge.

Controlling high blood pressure: Estimated percentage of members ages 65 to 85 diagnosed with hypertension whose blood pressure was below 140/90 in latest year.

LDL cholesterol screening: Proportion of members ages 65 to 75 with heart disease whose LDL (bad) cholesterol level was checked.

LDL cholesterol control: Proportion of members ages 65 to 75 with heart disease whose LDL (bad) cholesterol level was maintained below 100 milligrams/deciliter.

Mental and behavioral health
Depression—appropriate follow-up after diagnosis: Proportion of members who were newly diagnosed with depression, prescribed medication, and had at least three visits with a practitioner during the next 12 weeks.

Depression—adhering to medication for 12 weeks: Proportion of members who were newly diagnosed with depression, prescribed medication, and remained on the drug during the next 12 weeks.

Depression—adhering to medication for six months: Proportion of members who were newly diagnosed with depression, prescribed medication, and remained on the drug for at least six months.

Follow-up after hospitalization for mental illness: Proportion of members who were hospitalized because of mental illness and were seen for follow-up care within a week and again within a month of discharge.

Alcohol or drug dependence treatment initiated: Proportion of members who were diagnosed with alcohol or drug dependence and treated as inpatients or outpatients.

Alcohol or drug dependence treated for 30 days: Proportion of members who were diagnosed with alcohol or drug dependence and received at least two related services within 30 days of the initial treatment.

Other treatment measures
Medication for rheumatoid arthritis: Proportion of members who were diagnosed with rheumatoid arthritis and were prescribed an appropriate drug.

Monitoring of key long-term medications: Proportion of members who received a six-month supply of any of the following drugs and were being clinically monitored: ACE inhibitors, angiotensin receptor blockers (ARBs), digoxin, diuretics, or anticonvulsants.

Spirometry testing for COPD: Proportion of members whose diagnosis of chronic obstructive pulmonary disease was confirmed with a spirometry test.

Managing osteoporosis in women after fracture: Proportion of women ages 67 and above who had a fracture and either had a bone mineral density test or were prescribed an appropriate drug during the next six months.

Discussing urinary incontinence: Proportion of members who during the past six months discussed a urine leakage problem with their practitioner.

Avoiding high-risk medications: Proportion of members who did not receive certain medications that are considered potentially harmful in this age group.

Medicaid Plan Terms

Performance was measured relative to other plans, not to an independent standard.

Consumer assessment

Getting care
Getting care needed: Proportion of surveyed members who said it was easy to get appointments, preventive care, tests, and treatment.

Getting care needed quickly: Proportion of surveyed members who said it was easy to get appointments, preventive care, tests, and treatment promptly.

Satisfaction with physicians
How well doctors communicate: Proportion of surveyed members who gave plan's doctors a high rating in communications skills.

High rating of personal doctor: Proportion of surveyed members who gave their personal physician a high overall rating.

High rating of specialists: Proportion of surveyed members who gave plan's specialists a high overall rating.

High rating of care received: Proportion of surveyed members who gave the healthcare they received a high overall rating.

Satisfaction with health plan services
High rating of plan services: Proportion of surveyed members who gave the overall level of plan services a high rating.

Prevention

Children and adolescents
Well-child visits (birth to 15 months): Proportion of children who had at least six well-child visits from birth to 15 months old.

Well-child visits (3-6 years old): Proportion of children ages 3, 4, 5, and 6 who had at least one well-child visit.

Access for children (7-11 years old): Proportion of children ages 7 to 11 who had a visit with a primary-care physician.

Adolescent well-care visits: Proportion of members ages 12 to 21 who had at least one comprehensive well-care visit.

Immunizing children and adolescents
All immunizations at age 2: Proportion of children who got all recommended immunizations by their second birthday.

All immunizations at age 13: Proportion of adolescents who got all recommended follow-up immunizations by their 13th birthday.

Women's reproductive health
Timeliness of prenatal checkups: Proportion of women who gave birth and had a prenatal visit during the first trimester.

Postpartum care: Proportion of women who had a postpartum visit between three and eight weeks after delivery.

Cancer screening
Breast cancer screening: Proportion of women ages 40 to 69 who had a mammogram.

Cervical cancer screening: Proportion of women ages 21 to 64 who had a Pap test.

Other preventive services
Chlamydia screening (16-25 years old): Proportion of women ages 16 to 25 who were tested for chlamydia.

Treatment

Asthma
Medicate appropriately (5-9 years old): Proportion of asthmatic children ages 5 to 9 who were prescribed medications appropriately.

Medicate appropriately (10-17 years old): Proportion of asthmatic children and adolescents ages 10 to 17 who were prescribed medications appropriately.

Medicate appropriately (18-56 years old): Proportion of asthmatic adults ages 18 to 56 who were prescribed medications appropriately.

Diabetes
Retinal eye exams: Proportion of members ages 18 to 75 with type 1 or 2 diabetes who had a retinal exam.

Glucose testing: Proportion of members ages 18 to 75 with type 1 or 2 diabetes who had a blood glucose test.

Glucose control: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose blood glucose level was maintained below 9 percent.

LDL cholesterol screening: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose level of LDL (bad) cholesterol was checked.

LDL cholesterol control: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose LDL (bad) cholesterol level was maintained below 100 milligrams/deciliter.

Monitoring kidney disease: Proportion of members ages 18 to 75 with type 1 or 2 diabetes whose kidney function was checked.

Heart disease
Controlling high blood pressure: Proportion of members ages 18 to 85 who were diagnosed with hypertension and whose most recent blood pressure reading was below 140/90.

Advising smokers to quit: Proportion of smoking members ages 18 and above who were advised by a practitioner to stop.

Discussing stop-smoking strategies: Proportion of smoking members ages 18 and above who discussed methods or strategies for quitting with a practitioner.

Discussing stop-smoking medications: Proportion of smoking members ages 18 and above who discussed medications for quitting.

Other treatment measures
Monitoring of key long-term medications: Proportion of members who received a six-month supply of any of the following drugs and were being clinically monitored: ACE inhibitors, angiotensin receptor blockers (ARBs), digoxin, diuretics, or anticonvulsants.

Appropriate antibiotic use, children with URI: Proportion of children from 3 months to 18 years old who were not prescribed an antibiotic for up to three days after being diagnosed with a common cold.

Appropriate testing and care, children with pharyngitis: Proportion of children ages 2 to 18 who were diagnosed with a sore throat, prescribed an antibiotic, and tested for strep.

Appropriate antibiotic use, adults with acute bronchitis: Proportion of adults ages 18-64 who were not prescribed an antibiotic within three days of a diagnosis of acute bronchitis.