Health plans are rated on how well they perform in five different categories:
· Staying Healthy: Screenings, Tests and Vaccines (13 measures)
§ Members have at least one primary care doctor visit in the last year
§ The percentage of members who have had breast cancer screening in the last year
§ The percentage of members who have had colorectal cancer screening in the last year
§ The percentage of members with heart disease who have had cholesterol screening in the last year
§ The percentage of members with diabetes who have had cholesterol screening in the last year
§ The percentage of members who have had glaucoma testing in the last year
§ The percentage of members who have had osteoporosis testing in the last year
§ The percentage of members who have had an annual flu vaccine
§ The percentage of members who have had an annual Pneumonia vaccine
§ The percentage of members taking long-term medications who have been monitored
§ The percentage of members who were advised by their physician to start, increase, or maintain physical activity
§ The percentage of members who improved or maintained their physical health after two years
§ The percentage of members who improved or maintained their mental health after two years
· Managing Chronic (Long-Lasting) Conditions (10 measures)
§ Osteoporosis management
§ Eye exam to check for damage from diabetes
§ Kidney disease monitoring for members with diabetes
§ Percentage of plan members with diabetes whose blood sugar is under control
§ Percentage of plan members with diabetes whose cholesterol is under control
§ Controlling blood pressure
§ Rheumatoid arthritis management
§ Testing to confirm chronic obstructive pulmonary disease
§ Improving bladder control
§ Reducing the risk of falling
· Ratings of Health Plan Responsiveness and Care (6 measures)
§ Doctors who communicate well
§ Getting appointments and care quickly
§ Ease of getting needed care and seeing specialists
§ Overall rating of health care quality
§ Members’ overall rating of health plan
§ Customer service
· Health Plan Member Complaints and Appeals (4 measures)
§ Complaints about the health plan (number of complaints for every 1,000 members)
§ Health plan timely decisions about appeals
§ Fairness of health plan’s denials to member appeals, based on an independent reviewer
§ Beneficiary access problems Medicare found during an audit of the plan
· Health Plan Telephone Customer Service (3 measures)
§ Time on hold when customer calls health plan (minutes; seconds)
§ Accuracy of Information members get when they call the health plan
§ Availability of TTY/TDD services and foreign language interpretation when Members call the health plan
Drug plans are rated on how well they perform in four different categories:
· Drug Plan Customer Service (7 measures)
§ Time on hold when customer calls drug plan (minutes: seconds)
§ Time on hold when pharmacist calls drug plan (minutes: seconds)
§ Accuracy of information members get when they call the drug plan
§ Drug plan provides pharmacist with up-to-date and complete enrollment information about plan members
§ Drug plan’s timeliness in giving a decision for members who make an appeal.
§ Fairness of drug plan’s denials to a member’s appeal, based on an independent reviewer
§ Availability of TTY/TDD services and foreign language interpretation when members call the drug plan
· Member Complaints and Staying with Drug Plan (5 measures)
§ Beneficiary access problems Medicare found during an audit of the plan
§ Complaints by members about joining and leaving the drug plan (rate per 1,000 members)
§ All other complaints about the drug plan (per 1,000 members)
· Member Experience with Drug Plan (3 measures)
§ Drug plan provides information or help when members need it
§ Members’ overall rating of drug plan
§ Members’ ability to get prescriptions filled easily when using the drug plan
· Drug pricing and Patient Safety (4 measures)
§ Completeness of the drug plan’s information on members who need extra help
§ Drug plan provides accurate price information for Medicare’s Plan Finder web site and keeps drug prices stable during the year
§ Drug plan’s members 65 and older who received prescriptions for certain drugs with a high risk of side effects, when safer drug choices may be possible
§ Using the appropriate blood pressure medication recommended for people with diabetes