About the HMO Ratings


HMO Provides Recommended Care


Each year, a random sample of members from each HMO is selected and their records are reviewed to determine if their medical care meets national standards for recommended care. The HMO documents the care provided its members in their medical charts and in other HMO records. HMO records often include information from claims for medical services and prescription drugs.

Information from the HMOs’ records are collected and scored based on standards set by the HEDIS® (Healthcare Effectiveness Data and Information Set) performance measurement system. HEDIS® is described in greater detail below.

More than thirty-five HEDIS® measures are combined into a set of 9 important health conditions or topics, like Heart Care and Maternity Care. The measures are used to score HMOs on providing the right care for each health condition or topic. Then, these condition and topic scores are combined to calculate a single summary rating for the HMO: ‘HMO Provides Recommended Care.’ Back to top


Patients Rate Their Experience


Each year, a sample of HMO members is contacted by mail or phone to complete a survey called CAHPS® (Consumer Assessment of Healthcare Providers and Systems) This survey asks members about their experience with the care and services offered by the health plan. Usually, about one-third of the members who are contacted answer the survey. The report of survey results includes three summary ratings: ‘Rate Their HMO’, ‘Getting Care Easily’ and 'HMO Helps Members Get Answers.’ CAHPS® is described in greater detail below.

Back to top


Scoring and Rating Methods


HMO quality scores were constructed using the HEDIS® and CAHPS® quality performance systems. The quality measures are based on the services, care, and experiences of samples of commercial HMO members who were enrolled in the HMO throughout 2010. Medical chart and service records were collected and HMO members were surveyed in a standardized way through the coordination of the California Cooperative Healthcare Reporting Initiative (CCHRI).

Summary Score: 'HMO Provides Recommended Care’ gives the percent of members who got the right care for important health conditions or topics. Scoring a health condition or topic requires several steps.

  • First, scores are calculated for important measures of recommended medical care – for example, patients with hypertension or high blood pressure are lowering their blood pressure.
  • Second, measures that concern a similar health area like heart care are combined into a health condition or topic score. The measures are combined by giving them equal weight and calculating an average score.
  • Third, the health condition or topic scores are combined into a single summary rating using the same “equal weight and average score formula.”

The health plan is scored using one of four performance grades that are displayed as stars in the report card:

  • Excellent (4 stars) means that about 8 out of 10 HMO members got the right care.
  • Good (3 stars)means that about 7 out of 10 HMO members got the right care.
  • Fair (2 stars)means that almost 6 out of 10 HMO members got the right care.
  • Poor (1 star)means that less than 6 out of 10 HMO members got the right care.

For additional information on OPA's scoring methodology for HEDIS®, see this pdf document.

The rating category called ‘Patients Rate Their Experience’ has three summary ratings:

1. 'Rate Their HMO’, is an overall summary rating based on a single CAHPS® survey question that asks members to rate all of their experience with the health plan.

2. 'Getting Care Easily' is a summary rating of members' experiences in getting appointments with doctors and other providers when needed and getting tests, treatments and other care without delay.

3. The 'HMO Helps Members Get Answers' is a summary rating of members' experiences with customer service help, getting accurate information about how much treatment or care will cost a member, and getting accurate claim payment information.

Scores for the various CAHPS® topics are based on the percentage of members who gave high scores or answers ("always" or "usually" for most questions) to the survey question. For most questions, answers are scored using one of four possible choices ranging from the member “always” had a positive experience to the member “never” had a positive experience. For example, a member said that they “always” were able to get an appointment when needed or “usually” were able to get an appointment when needed. The answers for a set of related questions like ‘Doctor Communications’ are combined to create a combined score for that topic.

The rating called ‘Rate Their HMO’ is scored by calculating the percentage of members who gave the plan a high score of 8, 9 or 10 on a 0-10 scale. The plan is scored using one of four performance grades that are displayed as stars in the report card:

  • Excellent (4 stars) means that about 8 or more of every 10 HMO members rated the health plan highly.
  • Good (3 stars) means that about 7 of every 10 HMO members rated the health plan highly.
  • Fair (2 stars) means that about 6 of every 10 HMO members rated the health plan highly.
  • Poor (1 star) means that less than 6 of every 10 HMO members rated the health plan highly.

The ratings called ‘Getting Care Easily’ and ‘HMO Helps Members Get Answers’ are summary scores calculated by adding the topic scores that are included in that summary rating. The plan is scored using one of four performance grades that are displayed as stars in the Report Card:

  • Excellent (4 stars) means that about 9 out of 10 HMO members gave high scores/answers about their experience with the plan.
  • Good (3 stars) means that about 8 out of 10 HMO members gave high scores/answers about their experience with the plan.
  • Fair (2 stars) means that about 7 out of 10 HMO members gave high scores/answers about their experience with the plan.
  • Poor (1 star) means that fewer than 7 out of 10HMO members gave high scores/answers about their experience with the plan.

The rating categories called ‘HMO Provides Recommended Care’ and ‘Members Rate Their Experience’ and their associated health condition or topic-level scores include a “buffer zone” adjustment. This adjustment is needed because the formula is based on samples of members rather than all the members in an HMO. The “buffer zone” adjusts for the error that occurs in measurement and scoring. This “buffer zone” gives the benefit of the doubt to the HMO — if a score falls below a performance threshold, but within a half-point of that threshold, the HMO is assigned that next highest grade.

For additional information on OPA's scoring methodology for CAHPS, refer to this pdf document.

Back to top


“Too Few Members” and “Did Not Report”


On the HMO rating charts, scores range from one to four stars, with four stars being the highest rating. Sometimes there is not enough information on an HMO for a star rating. In those cases, you will see one of these messages:

  • Too Few Members: This means that the HMO did not have enough surveyed members (less than 100) to be scored.
  • Did Not Report: This means that the HMO would not report its results. This usually means that the HMO did not do well.

Back to top


How Reliable Are the Scores?


To get a clear picture of how well each HMO provides care and service to its members, information is collected from medical charts and member surveys. The ratings in the California Health Care Quality Report Card are based on information from HMO members who got health insurance through their job or purchased health insurance themselves. These ratings do not include information on members with health care coverage through Medi-Cal, Healthy Families, or Medicare.

The rating called ‘HMO Provides Recommended Care” tells an important story about how well the HMO and its doctors do in meeting national standards for good care, which includes ensuring that members get the right care and that they don’t receive unnecessary care or services. These ratings cover only a particular set of health conditions and topics and do not cover all aspects of medical care.

The ratings in ‘Patients Rate Their Experience’ are based on survey data that is collected in a way to show the usual experience of HMO members. Surveys were sent to adults who were randomly drawn from the HMO's full list of commercial members in 2011. The survey questions ask the member about their different experiences with health plan services, doctors and staff.

We recognize that it is possible that your experience with the HMO and its doctors or other providers/staff may differ from the ratings reported in the Report Card.

Back to top


Rate of Inquiries and Complaints About HMOs Received by DMHC


The rates were calculated by dividing the number of informational questions and formal complaints for each plan made to the Department of Managed Health Care (DMHC) Help Center in 2011 by the plan’s total number of HMO members within DMHC’s jurisdiction. The rate is stated as the number of contacts for every 10,000 members enrolled in the plan. For example, an HMO rate of 15 per 10,000 members means the Help Center received an average of 15 questions or complaints for every 10,000 members in that HMO.

Number of inquiries and complaints

The informational questions and complaints in this report are based on all contacts logged annually by the DMHC Help Center after excluding contacts for one of the reasons listed below. An informational question or complaint could be received by telephone, mail, e-mail or fax. Each such contact was counted separately, even if multiple questions or complaints came from a single enrollee.

The following types of questions and complaints were not counted:

  • Questions and complaints from individuals on Medicare or other health plans not regulated by DMHC, including those plans regulated by the California Department of Insurance
  • Requests for general information about COBRA, CA/Sr COBRA or Cal COBRA or general information about DMHC, OPA, HIPAA, Knox-Keene Act or health care in general
  • Contacts to inform DMHC about a case (“cc DMHC”)
  • Message/call back requests for DMHC staff
  • Wrong numbers
  • Request for copies of a complaint file
  • Questions about the status of pending DMHC complaints
  • Contacts from providers for the Provider Complaint Unit
  • Hang ups
  • Contacts classified as “unknown health plan”
  • Questions from the media
  • Misdirected mail


Number of enrollees

Each HMO’s membership count is needed to determine the rate of informational questions or complaints for that HMO. Each health plan is required to report its enrollment quarterly to DMHC. A health plan’s number of members is the average of the enrollment figures from four quarters in a given year. This enrollment figure is reported in the DMHC Annual Report. To eliminate duplication, only enrollment in full service health plans is considered; enrollment in dental and behavioral health plans is excluded.

Back to top


Number of formal complaints


Formal complaint data are from the DMHC 2011 Independent Medical Review (IMR) and Complaint Results report. To view these reports, go to the Departmental Reports page of the DMHC website.

DMHC Complaints Report provides the following:

  • Number and types of complaints closed by DMHC during the 2011 calendar year. A member’s complaint can include more than one issue. However, a complaint consisting of multiple distinct issues is counted as only one complaint against the health plan.
  • List of health plans licensed during the 2011 calendar year, the number of complaints closed for each health plan, the health plan’s average enrollment during the year, the number of complaints per 10,000 members, and the number of issues for each complaint category. Enrollment data are provided for comparison purposes.
  • Health plans are listed by the name that the plan is doing business as (“dba”) during 2011. Where a health plan is known by more than one name, the dba name is shown first with the additional name(s) in parentheses..
  • Data for resolved complaints that were determined to be within DMHC’s jurisdiction, eligible for review by DMHC, and resolved (closed) within the calendar year..
  • Complaints are classified in seven categories: Access, Benefits/Coverage, Claims/Financial, Enrollment, Coordination of Care, Attitude/Service of the Health Plan, and Attitude/Service of the Provider.

The ‘Rate of Formal Complaints Against HMOs Reviewed by DMHC’ chart combines the cases from each category to calculate the total number of formal complaints per plan.

Number of enrollees

The number of enrollees, or plan members, was obtained from the same source as the Rate of Inquiries and Complaints About HMOs Received by DMHC chart as explained above.

Back to top


Rate of Cases Decided in Favor of the HMO Member by the DMHC Independent Medical Review Process 2010-2011


HMO members can file an appeal when their health plan refuses to pay for medical services that the plan deems as not medically necessary. Through the Department of Managed Health Care (DMHC) Independent Medical Review (IMR) appeal process, your case will be reviewed by doctors who are not part of your health plan.

DMHC contracts with an independent external review organization to conduct the IMR. If the independent review organization overturns the plan’s denial, the plan must cover the service or treatment requested. Generally, the plan must authorize the service within 5 days of the IMR decision. Sometimes a health plan will reverse its original denial after a request for an IMR is made but before the formal review by the IMR doctors has occurred. This is called a plan reversal or withdrawal. Any of these actions is called a “service denial resolved in favor of plan member.”

This rate was calculated by dividing the HMO’s total number of IMR cases decided in favor of the member (withdrawn, reversed or overturned IMR cases) by the total number of members within DMHC’s jurisdiction during a two-year period (2010-2011). For example, a rate of 5 per 100,000 members means that for every 100,000 members, 5 plan members had medical service coverage approved through the IMR process. The health plan’s membership count is the average of its enrollment figures reported over four quarters in a given year. More information on what was measured, why it is important, and the source of information is found on the Rate of Cases Decided in Favor of HMO Member – Independent Medical Review (IMR) page.

Number of medical service denials decided in favor of the health plan member

The Department of Managed Health Care 2010 and 2011 Independent Medical Review and Complaint Results reports provide the number of each HMO’s medical services coverage denials overturned, reversed, or withdrawn through the IMR process. To view these reports, go to the Complaint Reports page of the DMHC website.

Number of HMO members

To determine the rate of service denials resolved in favor of the plan member, we must know how many members are in each HMO. Each health plan is required to report its enrollment (under DMHC jurisdiction) quarterly to DMHC. A health plan’s number of members is the average of its enrollment figures reported over four quarters in a given year. This enrollment figure is reported in the DMHC 2011 Independent Medical Review and Complaint Results report. To eliminate duplication, only enrollment in full service health plans is considered; the dental and behavioral health plans are excluded.

Back to top


Medical Group and HMO Ratings are not comparable


An HMO is a type of health insurance product. A medical group is a group of doctors who work with an HMO to give medical care to the HMO’s members. The ratings for HMOs and medical groups are not comparable because:

  • HMOs and medical groups keep different kinds of records. The information from these records is different.
  • We did not look at information from the same members in both the medical groups and HMOs, even when we were looking at medical care for the same health topic. For example, a person whose diabetes care was reviewed for her medical group may not have had her diabetes care reviewed for her HMO.
  • The quality of the care of HMOs and medical groups is measured in different ways. HMOs and medical groups are also rated differently.

Back to top


HEDIS®, CAHPS®, and the National Committee for Quality Assurance (NCQA)


HEDIS® and CAHPS® measures are important parts of a national system of accreditation of HMOs and some physician organizations (medical groups). These measures are administered by the National Committee for Quality Assurance (NCQA). NCQA is “a private, not-for-profit organization dedicated to improving health care quality everywhere.” The NCQA-sponsored accreditation process is voluntary but many health plans participate.

HEDIS® measures are based on randomly selected lists of members with a particular condition or need, like members who have had a heart attack or members who are children. The HMO gives information about whether or not the member got a particular service or the results of a test for that member. HMOs gather this information from the member’s medical chart and/or other records. The accuracy of this information is independently checked. The score usually is the percentage of members whose records show that they got a particular service or test result.

Most HEDIS® measures are collected once a year from the health plan members’ experiences in the previous year(s). However, HMOs are allowed to report on some HEDIS® measures every other year because the results do not change greatly over the span of just one year and collecting the HEDIS® data is expensive. A HEDIS® measure that can be reported every other year is known as a “rotated” measure. Some HMOs collected and reported the rotated measures information this year while others plans reported results for the past year. The OPA Health Care Quality Report Card uses the results from either year because generally results do not vary much from year to year.

To get information about members’ experiences with their HMO, randomly selected members of the HMO are asked to complete the CAHPS® survey. These members were mailed a copy of the CAHPS survey and asked to report about their experiences with the HMO and its doctors. Some members got follow-up phone interviews when they did not respond by mail. A research firm collected the survey responses and independent researchers scored the answers. The CAHPS® score usually is the percentage of members who answered the survey about a particular experience—like the helpfulness of plans' customer service staff. For more information about HEDIS®, CAHPS®, or NCQA visit www.ncqa.org

Back to top

Related links

311.500