What Star Rating Indicates
Like any other five-star quality rating system, the overall rating indicates the performance in key areas of the service delivered. As far as rating in health insurance plans is concerned the plans are rated in terms of medical care, member experience, and the plan administration. People shopping for health plans will find the quality rating system helpful to compare the quality and performance of different health plans available on exchange websites. All exchange health plans in the quality rating system are provided an overall rating on a 5-star scale, with 5 stars indicating the highest quality.
Categories on Which Plans Are Rated based on Performance and Score
The plan ratings depend on factors such as how the enrollees have rated the doctors in a plan’s network, how the plan run, and how easy it is getting information, appointment, tests, and treatments. The star rating system is designed to measure the scores and performance of the plans based on the following three categories:
Medical Care
The medical care assessment depends on how efficiently healthcare providers included in the network of the plans manage the health of the members such as vaccines, regular screenings, and other basic health services.
Member Experience
Member experience assessment depends upon the member satisfaction with their healthcare and doctors along with ease of obtaining services and appointments.
Plan Administration
It is a measure that shows how efficiently a plan runs taking into account customer service, presence of essential information presented in an apt manner, and the manner in which network providers facilitate appropriate tests and treatment.
Purpose of Rating System
The quality rating system ensures that Americans shopping for health plans have an independent tool to assess the quality and accuracy of all the qualifying health plans available through the Health Insurance exchanges. A star rating system may sound simple but is based upon 38 measurements of medical care, user satisfaction, and administrative excellence. All the available health plans are rated in a similar manner. The quality rating system was designed with the following objectives:
- Allow health insurance consumers to make informed decisions
- Facilitate oversight of health plans
- Provide actionable information to health plans to improve their service quality.
The star rating system was designed to address commitment towards the health insurance consumers and to provide the tool to find the best plan possible. The rating system also provides a feedback loop to the health plans so that they make essential improvements.
The methodology of Quality Rating
A methodology of quality rating is developed with the help of the input given by a panel of technical experts along with key stakeholders. The quality rating system is calculated by the CMS depending upon validated clinical quality and survey measure data submitted by the eligible enrollees for each plan available in the exchange. Then the measures are categorized into a hierarchy serving as the methodology foundation. At each hierarchy level, a score is calculated by the CMS thereby contributing to one global score.
The hierarchy level is designed in a manner so that consumers can easily understand the health plan quality rating information, and they give their review on specific aspects of quality performance like medical care and their experience. CMS then converts the scores of members into an overall global star rating on a 1 to 5-star scale, with 5 stars being the highest rating and 1 star being the lowest rating.
