How to Research the Quality of Health Insurance Plans
Strategies for Researching Health Insurance Plans
Measuring the quality of health insurance plans (quality of health care plans) is difficult, but more and more information is becoming available. There are certain things you can look for and questions you can ask.
Whatever kind of health insurance plan you are considering, you can research individual doctors and hospitals.
Many managed care plans are regulated by federal and state agencies. Indemnity plans are regulated by state insurance commissions. Your State Department of Health or insurance commission can tell you about any health insurance plan that interests you.
You can also find out if the managed care plan you are interested in has been "accredited," meaning that it meets certain standards of independent organizations.
Some states require accreditation if health care plans serve special groups, and some employers will only contract with health insurance plans that are accredited. Several national organizations review and accredit health insurance plans and institutions. You can contact these organizations (many are listed below) to see if a health care plan you are considering, or an institution in the health insurance plan, is accredited.
Another approach is to ask the health insurance plan how it ensures good medical care. Does the health care plan review the qualifications of doctors before they are added to the plan? Health insurance plans are supposed to review the health care that is given by their doctors and hospitals. How does the health insurance plan review its own services, and has it made changes to correct problems? How does the health care plan resolve member complaints? Some managed care plans survey members about their health care experiences. Ask the health insurance plan for a report of the survey results.
Some health insurance plans and independent organizations are also beginning to produce "report cards." These reports often include satisfaction survey results and other information on health insurance quality, such as if a health insurance plan provides preventive care (for example, shots for children and Pap smears for women) or if the health care plan follows up on test results. Report cards may also include information on how many members stay in or leave the health insurance plan, how many of the health care plan's doctors are board certified, or how long you may have to wait for an appointment. Report cards can only give you an idea of how a health insurance plan works and may not give a full picture of a health plan's quality. Ask health care plans if their activities have been reported in report cards developed by outside groups (business or consumer organizations).
Finally, you can talk to current members of the health insurance plan. Ask how they feel about their experiences, such as waiting times for appointments, the helpfulness of medical staff, the services offered, and the care received. If there are programs for your particular condition, how satisfied are the patients?
- Joint Commission on Accreditation of Healthcare Organizations
Evaluates and accredits nearly 20,000 health care organizations and programs including almost 12,000 hospitals and home care organizations, and more than 7,000 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. Visit Quality Check on the Joint Commission’s Web site for information on individual accredited organizations or for general information about assessing the quality of health care organizations.
- National Committee for Quality Assurance
Search for information about the quality of your managed care health plan. NCQA accredits HMOs and other managed care organizations.
- American Accreditation HealthCare/Commission/URAC
Accredits PPOs and other managed care networks. Contact for a list of accredited health care organizations.
- Accreditation Association for Ambulatory Health Care
Accredits outpatient health care settings such as ambulatory surgery centers, radiation oncology centers, and student health centers. Search for accredited ambulatory organizations.
- Community Health Accreditation Program
Accredits community, home health, and hospice programs; public health departments; and nursing centers.
- Consumer Coalition for Quality Health Care
A national, nonprofit organization of consumer groups advocating for consumer protections and quality assurance programs and policies. Contact with general questions about quality issues or for consumer materials on managed care and activities at the State level.