Main AHCA Website

AHCA’s main website for information on Medicaid, Health Quality Assurance and the Florida Center for Health Information and Policy Analysis.

Go >

Florida Health Information Network

This website provides information and resources relating to AHCA’s initiatives for Health Information Technology and Health Information Exchange.

Go >


FloridaHealthFinder.gov

Provides health education and information to compare and locate health care providers in Florida to make well-informed health care decisions.

Go >
AHCA Network of Websites

Florida Health Plan Consumer Information

Glossary

Quality of Care Indicators
Member Satisfaction
Health Plan Types and Product Lines
Financial Performance Indicators
Other Information about Health Insurance



Quality of Care Indicators

These are a set of measures that are used to report the performance of health plans. Consumers can use this information to help them to decide which health plan to choose. Purchasers of health care use the information to compare health plans and determine the relative value of care offered by managed care health plans. The measures allow the public to understand how well health plans achieve results that matter, such as, how effective and accessible is the care delivered. Data for these measures come from the Healthcare Effectiveness Data & Information Set (HEDIS). These measures are available only from managed care health plans, mainly HMOs. Below are descriptions of the specific HEDIS measures that are displayed on the website:

Keeping Kids Healthy

Adolescent Well-Care Visits: An indicator that measures the adequacy of well care visits for adolescents ages 12 through 21 years. A well care visit is a routine, preventive exam with a doctor to help ensure that adolescents are up-to-date with health screenings and immunizations. It estimates the percentage of adolescents who had one or more well care visits in the measurement year.

Childhood Immunization Status – Combo 3: A quality of care indicator that measures the percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HIB); three hepatitis B (HepB), one chicken pox (VZV), and four pneumococcal conjugate (PCV) vaccines by their second birthday.

Children & Adolescents’ Access to PCPs – 12 – 24 months: A quality of care indicator that measures the percentage of members ages 12 – 24 months who had a visit with a PCP.

Children & Adolescents’ Access to PCPs – 25 months – 6 years: A quality of care indicator that measures the percentage of members ages 25 months – 6 years who had a visit with a PCP.

Children & Adolescents’ Access to PCPs – 7 – 11 years: A quality of care indicator that measures the percentage of members ages 7 – 11 years who had a visit with a PCP.

Children & Adolescents’ Access to PCPs – 12 – 19 years: A quality of care indicator that measures the percentage of members ages 12– 19 years who had a visit with a PCP.

Chlamydia Screening in Women: A quality of care indicator that measures how often women are screened for the sexually transmitted disease Chlamydia. It estimates the percentage of sexually active females, ages 16 through 20 years, who have had at least one test for Chlamydia during the measurement year or the year prior. Score shows percentage of eligible members who received a screening.

Immunizations for Adolescents – Combo 1: A quality of care indicator that measures the percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.

Lead Screening in Children: A quality of care indicator that measures the percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

Well-Child Visits, First Fifteen Months of Life, Six or More Visits:  An indicator that measures the adequacy of well care for infants through the first 15 months of age. A well child visit is a routine, preventive exam with a pediatrician to help ensure that children are up-to-date with health screenings and immunizations. It estimates the percentage of children who had six or more well care visits by the fifteenth month of age.

Well-Child Visits, Ages 3-6 Years:  An indicator that measures the adequacy of well care for children ages 3 through 6 years. A well child visit is a routine, preventive exam with a pediatrician to help ensure that children are up-to-date with health screenings and immunizations. It estimates the percentage of children who had one or more well care visits in the measurement year.

Keeping Adults Healthy

Adult BMI Assessment: A quality of care indicator that measures the percentage of members 18 – 74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.

Adults’ Access to Preventive Health Services: A quality of care indicator that measures the percentage of members 20 years and older who had an ambulatory or preventive care visit during the measurement year.

Breast Cancer Screening: A quality of care indicator that measures how often women are screened for breast cancer. It estimates the percentage of females, ages 50 through 74 years, who have had at least one mammogram during the measurement year or the year prior. Early detection and treatment increase the survival rate of breast cancer patients. Score shows percentage of eligible members who received a screening.

Cervical Cancer Screening: A quality of care indicator that measures how often women are screened for cervical cancer. It estimates the percentage of females between the ages of 21-64 years who had a Pap test during the past three years. PAP tests have been credited with reducing the number of deaths from cervical cancer. Score shows percentage of eligible members who received a screening.

Chlamydia Screening in Women: A quality of care indicator that measures how often women are screened for the sexually transmitted disease Chlamydia. It estimates the percentage of sexually active females, ages 21 through 24 years, who have had at least one test for Chlamydia during the measurement year or the year prior. Score shows percentage of eligible members who received a screening.

Chlamydia Screening in Women (combined age groups): A quality of care indicator that measures how often women are screened for the sexually transmitted disease Chlamydia. It estimates the percentage of sexually active females, ages 16 through 24 years, who have had at least one test for Chlamydia during the measurement year or the year prior. Score shows percentage of eligible members who received a screening.

Living With Illness

Controlling High Blood Pressure: A quality of care indicator that estimates the percentage of adults, ages 18 through 85 years, diagnosed with high blood pressure, who had their blood pressure adequately controlled (systolic pressure under 140 mm and diastolic pressure under 90 mm) during the measurement year. Persons with uncontrolled high blood pressure have a greater risk of stroke and heart disease.

Diabetes Care: HbA1c Testing: A quality of care indicator that estimates the percentage of members ages 18 – 75 years with diabetes (type 1 and type 2) who had a blood sugar (glucose) screening in the measurement year.

Diabetes Care: HbA1c – Good Control: A quality of care indicator that estimates the percentage of members ages 18 – 75 years with diabetes (type 1 and type 2) who had a screening for HbA1c in the measurement year and whose measurement for the most recent test was <8.0%. A value below 8.0% indicates that the member’s blood sugar (glucose) level is under control.

Diabetes Care: LDL Screening: A quality of care indicator that estimates the percentage of diabetic plan members, ages 18 through 75 years, who had a screening for cholesterol (LDL-C) in the measurement year. This measure, among the other diabetes care measures, provides a comprehensive view of how providers and the health plan address and help manage this disease. Score shows percentage of eligible members who received a screening.

Diabetes Care: LDL-C Control: A quality of care indicator that estimates the percentage of diabetic plan members, ages 18 through 75 years, who had a screening for cholesterol (LDL-C) in the measurement year and whose measurement for the most recent test was below 130 ml/dL. A value below 130 ml/dL indicates that the member's diabetes is under control. Score shows percentage of eligible members who received care.

Diabetes Care: Eye Exam: A quality of care indicator that estimates the percentage of diabetic plan members, ages 18 through 75 years, who received an eye exam in the measurement year. Diabetes is the leading cause of adult blindness in the U.S., which makes it important that diabetics have their eyes examined regularly so that appropriate treatment can be initiated at the first sign of a problem. Score shows percentage of eligible members who received an exam.

Diabetes Care: Nephropathy: A quality of care indicator that estimates the percentage of diabetic plan members, ages 18 through 75 years, who were screened or treated for kidney disease (diabetic nephropathy) during the measurement year. Diabetes affects multiple organs in the body including the kidneys. Kidney failure can be prevented if detected and addressed in the early stages. Score shows percentage of eligible members who received a screening.

Use of Appropriate Medications for People with Asthma: A quality of care indicator that estimates the percentage of children and adults, ages 5 through 64 years, with persistent asthma who were prescribed medications appropriate for long-term control of asthma during the past year. Some medications provide short-term relief of asthma symptoms; however, these medicines cannot prevent subsequent asthma attacks. Score shows percentage of eligible members who received care.

Mental Health Care

ADHD Medications Follow-Up – Initiation: A quality of care indicator that measures the percentage of children ages 6 – 12 years who had one follow-up care visit within 30 days of when the first newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication was dispensed.

Antidepressant Medication Management – Acute: A quality of care indicator that measures the percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication for at least 12 weeks.

Follow-Up after Mental Illness Hospitalization – 7 Day: A quality of care indicator that measures the percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner and who received follow-up within 7 days of discharge.

Follow-Up after Mental Illness Hospitalization – 30 Day: A quality of care indicator that measures the percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner and who received follow-up within 30 days of discharge.

Frequency of Ongoing Prenatal Care: A quality of care indicator that measures the percentage of Medicaid deliveries that had 81% or more of expected prenatal visits.

Postpartum Care: A quality of care indicator that measures the percentage of women who had a postpartum visit on or between 21 and 56 days after delivery.

Prenatal Care: A quality of care indicator that measures the percentage of pregnant women who began prenatal care during the first trimester of pregnancy or within 42 days of enrollment. Prenatal care is a form of preventive medicine that helps to reduce low weight births and provides help for new mothers. Score shows percentage of eligible members who received care.

HEDIS

Healthcare Effectiveness Data & Information Set (HEDIS):   A set of measures that are used to report the performance of health plans. The measures evaluate the organizational structure and systems of the HMO and the performance in delivering care. HEDIS measures ensure that results are comparable across health plans. HEDIS was created by the National Committee for Quality Assurance (NCQA).


Member Satisfaction

Obtaining information on a member's satisfaction with a particular health plan is a key component in the decision of choosing a health plan. This information provides a general indication of how well the plan meets the members' expectations. Information on member satisfaction is obtained from the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS). Health care organizations, health care purchasers and consumers use CAHPS results to (1) assess the patient-centeredness of care, (2) compare health plan performance, and (3) improve quality of care. Below are descriptions of the specific CAHPS questions that are displayed on the website:

Consumer Assessment of Healthcare Providers and Systems (CAHPS):  A survey that assesses the member satisfaction with the performance of the health plan. The CAHPS survey makes it possible for consumers and purchasers to view understandable and usable comparative information across plans and over time. CAHPS was developed by the U.S. Department of Health and Human Services.

Ease in Getting Needed Care:  Score shows percent responding "Usually" & "Always." The score for this item is the average score for the following questions:

  • How often did you get an appointment to see a specialist as soon as you needed?
  • How often was it easy to get the care, tests, or treatment you needed?

Ease in Getting Care Quickly:  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

  • When you needed care right away, how often did you get care as soon as you needed? 
  • Not counting the times you needed care right away, how often did you get an appointment for check-up or routine care at a doctor's office or clinic as soon as you needed?

How Well Doctors Communicate:  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

  • How often did your personal doctor explain things in a way that was easy to understand?
  • How often did your personal doctor listen carefully to you?
  • How often did your personal doctor show respect for what you had to say?
  • How often did your personal doctor spend enough time with you?

Getting Help from Customer Service:  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

  • How often did your health plan’s customer service give you the information or help you needed? 
  • How often did your health plan’s customer service staff treat you with courtesy and respect? 

How Well Plan Processes Claims:  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

  • How often did your health plan handle your claims quickly?
  • How often did your health plan handle your claims correctly?

Overall Plan Satisfaction:  "Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?"  Score shows percent responding "8", "9", or "10"

Rate the Number of Doctors to Choose From:  "How would you rate the number of doctors you had to choose from?"  Score shows percent responding "Very Good" or "Excellent."

Recommend Health Plan to Family or Friends:  "Would you recommend your health plan to your family or friends?"  Score shows percent responding "Probably Yes" or "Definitely yes."

Would You Select Your Current Plan Again:  "If today you could select any health plan company in your area, would you select your current plan again?"  Score shows percent responding "Probably Yes" or "Definitely yes."

Shared Decision Making: Score shows percent responding "Yes." The score for this item is the average score for the following questions:

  • Did you and a doctor or other health provider talk about the reasons you might want to take a medicine?
  • Did you and a doctor or other health provider talk about the reasons you might not want to take a medicine?
  • When you talked about starting or stopping a prescription medicine, did a doctor or other health provider ask you what you thought was best for you?

 

Health Plan Types and Product Lines

There are many kinds of health insurance plans available to the consumer. Basically, health insurance can be grouped into two main types, traditional health insurance and managed care. With traditional health insurance, you select a health care provider, such as a doctor or hospital. You may have to pay for services when rendered and then submit the bill to the insurance company for reimbursement. Managed care combines the delivery and financing of health care services. This limits your choice of doctors and hospitals, but you usually pay less for medical care (for example, doctor visits, prescriptions, and surgery) than you would with traditional health insurance. The managed-care network controls health care services. Below are some of the most popular health plan types:

Health Maintenance Organization (HMO):  An organized system for providing comprehensive, prepaid health care. HMOs provide care in a defined geographic area; provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; provide care to a voluntarily enrolled group of persons; require their enrollees to use the services of designated providers; and receive a predetermined, fixed, periodic prepayment made by or on behalf of the member. HMOs are licensed and reviewed by government agencies such as the Agency for Health Care Administration (AHCA) to ensure compliance with state and federal regulations.

Exclusive Provider Organization (EPO): EPOs are individual providers or groups of providers who have entered into written agreements with an insurer to provide health care services to subscribers. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but you cannot go outside of the network for care. EPO members usually do not receive any reimbursement or benefit if they choose to visit medical care providers outside of the established network, except for certain emergency cases. EPOs are also licensed and reviewed by government agencies including the Agency.

Preferred Provider Organization (PPO): The PPO plan gives you the choice of obtaining health care services from any network (the plan's select group of health care providers) or any non-network health care provider. In most PPO plans, your primary care physician does not control your use of specialists. PPO plans usually require that you pay co-insurance or make a co-payment at the time services are rendered. If you choose to receive services out of the network, it may result in higher out-of-pocket costs for you. PPO plans are not regulated by the Agency, but are regulated by the Florida Department of Financial Services.

Point of Service (POS):  This plan adds an out-of-network benefit to HMOs. The POS plan allows you to decide whether to use a network or non-network health care provider at the time care is needed. If you use a non-network health care provider, the plan may only pay 50 to 80 percent of your health care expenses and you may be responsible for paying a deductible and co-insurance charges.


Product Line:  This refers to the population that the health plan covers. In the Florida Health Plans Consumer Information website there are four product lines: Commercial, Florida Healthy Kids, Florida Medicaid and Medicare.

Commercial:  This is health care coverage paid for by employers or individual consumers.

Florida Healthy Kids:  A public-private initiative designed to improve access to comprehensive health insurance for the state's uninsured children. Healthy Kids acts as a single payer financing mechanism to pay premiums to commercial health plans who assume the insurance risk. This program is unique because it is designed to provide affordable access to health insurance coverage for working families for whom the payment of the full premium would be out of reach.

Florida Medicaid: Medicaid is a state-administered medical assistance program that provides access to health care for low-income families and individuals. Medicaid also assists aged and disabled people with the costs of nursing facility care and other medical expenses. The Florida Medicaid program offers the following types of managed care health plans:

  • Health Maintenance Organizations (HMOs): Corporations that contract with a network of health care providers, such as physicians, hospitals, and laboratories, to provide prepaid health services and place emphasis on preventive health care through effective quality and cost controls.
  • Provider Service Networks (PSNs): Health care delivery systems, owned and operated by hospitals, physician groups, or other providers. PSNs have a network of providers and facilities, which provide health care to enrollees.
  • Children’s Medical Services Network (CMS Network or CMSN): A program operated by the Department of Health that provides services for children from birth through age 21 with special health care needs.

Medicare: A federal health insurance program that serves people age 65 and older or disabled persons, regardless of income.


Other Information about Health Insurance

Accreditation:  Accreditation is the health care industry standard for quality performance and measurement. Accreditation is a voluntary process by which an impartial organization will review a company's operations to ensure that the company is conducting business in a manner consistent with national standards. There are three national organizations that provide accreditation to Florida managed care health plans: Accreditation Association for Ambulatory Health Care (AAAHC), National Committee for Quality Assurance (NCQA), and Utilization Review Accreditation Commission (URAC).

Accreditation Status:  The accreditation status summarizes how well a plan performs overall. Plans with higher levels of accreditation can generally be expected to provide better care and service than plans with lower levels of accreditation. The highest level of accreditation is "Full". The second highest level is labeled "One-Year" by AAAHC and NCQA, while the second highest level is labeled "Conditional" by URAC.

Accreditation Association for Ambulatory Health Care (AAAHC):  A private, not-for-profit accreditation organization that reports on the quality of managed care plans.

National Committee for Quality Assurance (NCQA):  A private, not-for-profit accreditation organization that reports on the quality of managed care plans.

Utilization Review Accreditation Commission (URAC):  A private, not-for-profit accreditation organization that reports on the quality of managed care plans.


Agency for Health Care Administration (AHCA):  The state agency that licenses and regulates health care facilities and jointly regulates health maintenance organizations in Florida along with the Florida Office of Insurance Regulation. AHCA also publishes reports on health care data and statistics and administers the Florida Medicaid program that provides health care to Florida's low-income citizens.

Coverage Areas by County:  The names of the Florida counties in which a health plan is available. Typically, this means the county where a person lives and/or works.

Department of Financial Services (DFS):   The state agency that oversees rates and regulations in the insurance, banking and finance industries of Florida and helps consumers with problems related to financial services, including banking, securities and insurance. The Department of Financial Services includes the Office of Insurance Regulation.

Enrollment:  Figures display the total number of covered lives (subscriber and dependents) in a health plan, specific to product line.  Many health plans have more than one product line.

Health Plan Name:  This displays the name for the health plan company, as provided by Florida's Office of Insurance Regulation.  Within an individual company there may be several brand names for separate health plans.

Small Group Health Plan Premium Rates:  Consumers can view average small-group health insurance premium rates for many health plans available in Florida at the Small Employer Sample Rate Search website.  At this site, maintained by the Florida Office of Insurance Regulation, the viewer can compare rates across many health insurance plans tailored to their health care needs.

Subscriber Assistance Program (SAP): A program to provide assistance to managed care plan members whose grievances are not resolved to their satisfaction by the managed care plan. The consumer must first complete the entire grievance process of the health plan before filing a grievance with the program, unless the grievance is of an urgent nature. Under this program, a panel reviews the grievance and makes a recommendation to AHCA or the Florida Department of Financial Services.

Website:  The Internet address for a particular health insurance company.  Go to a plan's website for the most comprehensive and up-to-date information of the plan's benefits, coverage area, provider network and other information.

We Appreciate Your Feedback
1. Did you find this information useful?
         Yes
         No

2. Would you recommend this website to family and friends?
         Yes
         No