Covered California’s quality ratings show how our health plans compare on helping members get the right medical care and on member-reported experiences of care and service.
Star Ratings for 2021
Plans are rated on a scale of one to five stars. To assign the star rating, each health plan’s results are compared to about 200 health plans nationwide. A five-star plan means that that health plan scored among the top plans nationwide; a one-star rating means the plan’s score was among the lowest.1
* Quality ratings are reported for a health plan product after its first two years with Covered California.
**Not enough data to calculate a score.
How Quality Is Measured
Covered California has been reporting quality ratings since day one. These ratings play an important role in helping Californians get better care at affordable prices. A number of California health plans perform well in most areas and no plans were scored an overall 1-star rating. But the performance standards set by the highest-performing plans, in California and nationwide, tells us that some plans can do better.
Covered California is working with its health insurance companies to improve the quality and overall value of the coverage they offer. Key efforts include seeing that every member is matched to a primary care clinician; connecting the sickest enrollees with health care organizations that have demonstrated superior-quality care; identifying and eliminating gaps in good care across populations of people who differ by ethnicity, race or income; and advancing health care technology to improve care and eliminate unsafe practices.
Covered California provides consumers with an overall quality rating and individual ratings for three major aspects of health plan performance.
Overall Quality Rating: An overall quality rating is constructed for each health plan by summarizing all of their quality results. To be rated the health plan must have at least two of the three component scores to include the Getting the Right Care score.
Getting the Right Care: Each year, a sample of members from each health plan is selected and their records are checked to compare their medical care with national standards for care and treatments that are proven to help patients. More than 30 aspects of health care quality are tracked by checking patients’ medical charts and the billing records sent by doctors and hospitals. These quality measures include things like how well the health plan and its doctors help people control high blood pressure, lower their cholesterol and get the right medications.
Members’ Care Experience: Members’ experiences with their doctor and care are based on a survey that asked about their recent experiences when visiting the doctor and getting medical care. About one of every five people who got a survey in the mail or by phone sent in their answers, with about 250 members from each plan completing surveys.
Plan Services for Members: A sample of plan members’ records is checked to see if patients got unnecessary care — services that could be harmful and a waste of your time and money. And, another part of the member survey is used to report on members’ experiences in getting help and information from the health plan’s customer service staff. One plan had no “Plan Services for Members” rating because too few members answered those survey questions.
1 “Plan quality ratings and enrollee survey results are calculated by Covered California using data provided to Covered California by health plans. Due to the COVID-19 pandemic’s impact, Covered California collected the data for 2019 and calculated the Quality Ratings using the higher-of the plan’s 2019 or 2018 results. For more information, please see CMS’ Health Insurance Marketplace Quality Initiatives website at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/ACA-MQI/ACA-MQI-Landing-Page.”
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