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