What Do NCQA’s Five-Star Ratings Mean?

There are numerous rating systems these days: Rating the top movies, the best restaurants, or that little yellow full-or-half-star on popular e-commerce sites that indicate how satisfied customers were with their purchases.

People pay attention to health plans who successfully achieve a Five-Star Rating, because it’s publicly available through NCQA and often promoted on the health plan’s website. Achieving a high rating takes hard-work and determination by health plan leaders. It also means that the health plan must maintain or continually work to improve the rating to stay in good graces with its members and prospective members.

Ratings explained

According to Healthcare.gov, a health plan’s Five-Star Rating includes three categories:

Member experience – Based on surveys of member satisfaction with:

  • Their health care and doctors
  • Ease of getting appointments and services

Medical care – Based on how well the plans’ network providers manage member health care, including:

  • Providing regular screenings, vaccinations, and other health services
  • Monitoring conditions

Plan administration – Based on how well the plan runs, including:

  • Customer service
  • Access to needed information
  • Network providers ordering appropriate tests and treatment

All health plan ratings are calculated the same way, using uniform information sources, and building credibility with consumers.

With social determinants being an increased focus in population health, what are the actions and interventions that support health plan accreditation and star ratings? Social determinant interventions are tracked, but what does that mean to the consumer? Developing member assessments that capture data and populate a care plan that can be shared with one or multiple providers. What’s the result? It is better coordinated care and improved outcomes.

IQVIA’s Healthcare Center of Excellence can help health plans challenged with achieving the social determinant requirements, because they often have, but may not know, which ones they have.

Quality measurements

Health plan ratings are scaled 1 to 5 (5 being the highest), which accounts for quality, the member’s experience, medical care, and health plan administration. This gives the consumer an objective way to compare health plans, as they shop for health insurance.

Consumers pay close attention to these ratings when they’re on the market selecting a health plan, especially if their employer offers several plan options to choose from. If the health plan rates well, then consumers will purchase from them.

Is there room for the health plan to improve? How can it achieve a higher rating?

One place to start is looking at the quality measurements, including Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Health Plans Survey (CAHPS®), that measure the health plan’s quality and what people are saying publicly about the health plan.


NCQA uses HEDIS to measure a health plan’s quality. HEDIS evaluates how good the care was and how often people get preventive care ― tests and treatments that move them towards better health. HEDIS also measures whether people with chronic conditions, such as asthma, diabetes, or high blood pressure, get care that improves their health. HEDIS also includes measures for children and older adults. HEDIS evaluates whether doctors, other clinicians, and health insurers make the best use of available healthcare resources and whether they provide unnecessary care that may harm the patient.


CAHPS is a survey tool from the Agency for Healthcare Research and Quality (AHRQ) that answers the question of what people are saying about their care — an important part of any health plan rating.

CAHPS asks these questions:

  • Did you get care when you needed it?
  • Was the customer service staff helpful and polite?
  • Did the doctor listen to you and explain things in a way you could understand?

Why ratings matter 

By combining HEDIS and CAHPS results, NCQA accredits and rates health plans so consumers know where to find the best value. NCQA shares what it learns from companies who buy health insurance (the employers) and with the people who use healthcare (consumers), so they know where to get high-quality care.

Ratings provide consumers with the information they need to find high-quality healthcare. NCQA performs its ratings review, and shares ratings broadly, at no cost to the public.

Health care quality means getting the right care, in the right amount, at the right time.

  • Right care: Treatments that are determined to work and that fit the patient’s values, lifestyle and circumstances.
  • Right amount: Not getting care you need is a problem of “too little too late.” Getting care that doesn’t help you is “too much.” Another issue is getting multiple tests from doctors who don’t share information with each other.
  • Right time: Getting care when you need it is important — often, the best treatment is care that keeps you from getting sick in the first place or preventing a worsening condition and a condition that can be managed.

The ability for a health plan to rise to the next level is a significant accomplishment, but sometimes maintaining a current rating (or accreditation) is just as important. Some health plans will never receive a 5-Star Rating because they may not meet all the requirements (e.g., a Level 1 Trauma Center in their network), but maintaining their current rating — 3 or 4 Stars — is important.

Health plan ratings include accredited and non-accredited health plans. The 2018-2019 Health Insurance Plan Ratings reviewed 1,500 plans and rated more than 1,000 private (commercial), Medicare and Medicaid plans, based on their combined HEDIS®, CAHPS®, and NCQA Accreditation standards.

NCQA’s Health Insurance Plan Ratings for 2019 – 2020 were updated on June 30 and will be released to the public on September 20.

Moving up

Certain HEDIS measurements are included within NCQA, in order that an audit can help a health plan improve its ratings. The point of a better Star Rating is the public recognition, as well as improved reimbursement rates.

The difference between receiving a 3-Star Rating or 4-Star Rating is the reimbursement received. If the health plan has not achieved all the requirements in a rating, they will receive a lower reimbursement.

A health plan can improve its rating, for example, if they retrospectively notice that there are high incidents within certain segments of its population. They may recognize an area where they need to create a campaign with their network providers to track these patients.

An example is the health plan who may want more members to receive mammograms, and when the patient is asked, they respond that they went to a mobile mammography van in their community. The interaction was self-reported, so there is no record.

The Healthcare Technology practice can help health plans determine new and creative ways to collect and report quality data, use existing data with master data management techniques and reporting skills to determine avenues where hidden data can be used. We can identify and help set monitoring rules for early alerts when any domain is close to compromise. IQVIA’s Healthcare Technology practice can also create beneficiary surveys that maintain and increase the satisfaction domain rating with creative brainstorming regarding beneficiary response rates. It’s a good idea to have a fresh set of eyes review the health plan’s policies and procedures, annually.

To learn more about the IQVIA’s Population Healthcare practice, please reach out to Chris McShanag, vice president, population health.