The world of healthcare can sometimes feel like a maze, with countless options and confusing jargon. Enter the National Committee for Quality Assurance (NCQA), which evaluates health plans nationwide, including Medi-Cal programs, to assess their performance and quality. 

Find out what the NCQA is, how it evaluates health plans, and what San Francisco Health Plan’s rating means for you and your family here. 

What Is the National Committee for Quality Assurance? 

The NCQA is a non-profit organization that aims to improve the quality of healthcare in the United States. They develop standards to evaluate and compare the performance of managed care plans, healthcare providers, and health systems. 

What Are NCQA Ratings? 

NCQA ratings are a way to measure the quality of care provided by health plans. They’re based on performance metrics that assess various areas, including preventative care, chronic disease treatment, and patient satisfaction. 

NCQA ratings and accreditation are highly regarded in the healthcare industry and serve as a recognized symbol of excellence. 

What Is Medi-Cal? 

Medi-Cal, a government-sponsored healthcare program that provides coverage for low-income individuals and families in California, is one of the areas where the NCQA focuses its assessments. 

San Francisco Health Plan (SFHP) is a prominent Medi-Cal plan that undergoes NCQA evaluation to determine its quality of care. 

What Is San Francisco Health Plan’s NCQA Medi-Cal Rating?

Currently, SFHP is accredited, has an NCQA rating of 4 out of 5 stars, and will receive a rating for 2023 in October; this is the highest rating for an NCQA Medicaid HMP in California. The rating is based on SFHP's level of care, member satisfaction, and continuous quality improvement. 

What Are the NCQA Accreditation Levels? 

NCQA’s accreditation levels represent the different tiers that health plans can achieve. A plan's overall performance and adherence to the NCQA's rigorous standards determine where it stands. The accreditation levels include:

  • Accredited with Commendation - Health plans at this level have exceeded the NCQA's standards and have demonstrated exceptional performance in various areas. This recognition means the plan has exceeded expectations in delivering outstanding care and service.

  • Accredited - Indicates that the health plan has met all the essential requirements set forth by the NCQA. It demonstrates a commitment to providing high-quality care and meeting the needs of its members.

  • Not Accredited - The health plan did not meet the required standards set by the NCQA and may need to improve specific areas to enhance the care provided.

What Is the NCQA Rating Methodology?

The organization uses various scales to distinguish clinical quality between plans, such as: 

  • The Healthcare Effectiveness Data and Information Set (HEDIS) - Assesses how well plans provide preventative and chronic care services, such as immunizations, screenings, and diabetes management. 

  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS) - Surveys plan members about their satisfaction and experience with their healthcare providers and services. 

  • The Accreditation Status - Reflects how well a plan meets the NCQA’s requirements for improvement, consumer protection, network adequacy, and utilization management. 

Why Is NCQA Accreditation Important?

NCQA ratings and accreditation are important because they provide standardized quality measures in healthcare. They also drive improvement, enhance accountability, and enable individuals to make informed decisions about their healthcare options. 

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