NCQA Health Plan Accreditation. Rigorous. Flexible. Superior.

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1 NCQA Health Plan Accreditation Rigorous. Flexible. Superior.

2 Health Plan Accreditation Rigorous. Flexible. Superior. Health plans operate in a competitive marketplace, often vying for business with local, regional and national firms. NCQA s Health Plan Accreditation 2013 helps organizations demonstrate their commitment to quality and accountability, and provides substantial competitive advantages over plans with other or no accreditation. The latest version of NCQA s Health Plan Accreditation is the superior choice for insurers because it: Prepares Plans for Exchanges. The new program helps organizations meet eligibility requirements for participation in state-based and federal health insurance Exchanges. Emphasizes Performance as Never Before. Accreditation 2013 is the first version of NCQA Accreditation in which standards and performance on HEDIS and CAHPS measures count equally in scoring. By giving equal weight to standards and performance measures, NCQA Accreditation encourages and rewards high performance now, more than ever. Provides a Glide Path to Accreditation. Health Plan Accreditation 2013 combines formerly separate evaluation programs so plans with varied goals and capabilities can earn health care s highest badge of quality, the NCQA seal. The glide path involves three options or steps: Interim Evaluation is for plans that need accreditation before or right after they open for business. It focuses on insurers policies and procedures, does not include HEDIS/CAHPS reporting and is valid for 18 months. First Evaluation is for plans new to NCQA and leads to accreditation that is valid for three years. HEDIS/CAHPS reporting is required only in the final year, helping plans prepare for their Renewal Evaluation. Renewal Evaluation is available to NCQA-Accredited plans seeking to extend their accreditation another three years. HEDIS/CAHPS reporting is mandatory, and performance results count in the scoring. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

3 Flexibility: Three Ways to Earn Accreditation Today s complex insurance marketplace compels plans to distinguish themselves by competing on quality and value. The options of Interim, First and Renewal Evaluation facilitate accreditation for a range of plans regardless of their longevity or familiarity with HEDIS reporting. Interim 1 First 1 Renewal Submit Documentation Quality Management and Improvement: Does the plan measure its performance and make improvements when needed? Utilization Management: Does the plan notify members and practitioners about coverage decisions within required time frames? NCQA Standards Credentialing: Does the plan verify clinicians credentials? Members Rights and Responsibilities: Does the plan have a written members rights and responsibilities policy? Member Connections: How does plan distribute information and promote wellness and prevention? + + (HEDIS & CAHPS scoring option for Excellent or Commendable status) HEDIS Performance Measures (Clinical) + CAHPS (Patient Experience) Decision BY NCQA Interim Status 2 Excellent, 3 Commendable, Accredited or Provisional Status Excellent, Commendable, Accredited or Provisional Status Promotion of Accreditation Status On Health Plans Marketing Materials NCQA Seal On NCQA s Health Plan Report Card Accreditation Star Ratings Access and Service How well does the health plan provide its members with access to needed care and good customer service? Qualified Providers Does the health plan check whether physicians have had sanctions or lawsuits against them? Staying Healthy Does the health plan give its doctors guidelines about how to provide appropriate preventive health services? Getting Better How does the health plan evaluate new medical procedures, drugs and devices to ensure that patients have access to the most up-to-date care? Living With Illness Does the plan have programs in place to help patients manage chronic conditions like asthma? 1 For plans that have not held NCQA Accreditation in last 24 mos 2 NCQA Accreditation Star Ratings are not applicable for Interim Status. 3 Excellent or Commendable requires HEDIS & CAHPS.

4 Get Ready for Exchanges Exchanges will reshape individual and small business insurance markets in most states. New rules and subsidies make these markets attractive to a variety of health plans and to millions of previously uninsured consumers. Accreditation is an important prerequisite of Exchange participation, and the Centers for Medicare & Medicaid Services identifies NCQA as an approved accreditor. Federal accreditation requirements for Exchanges mirror the NCQA Health Plan Accreditation 2013 program, which contains all the key elements the law requires. Exchange Requirements NCQA Accreditation Local performance on clinical quality measures such as HEDIS 3 Patient experience ratings on a standardized CAHPS survey 3 Consumer Access 3 Utilization Management 3 Quality Assurance 3 Provider Credentialing 3 Complaints and Appeals 3 Network Adequacy and Access 3 Patient information programs that help enrollees find a doctor 3 Match Your Accreditation to Your Exchange Strategy Whether your organization is new to NCQA, or new only to Exchanges, there is an accreditation path to help you compete in the new marketplace. Start No Yes Yes No Yes No automatic reviewed

5 The Industry s Gold Standard NCQA Accreditation is the most comprehensive evaluation in the industry, and the only assessment program that bases results on actual measurement of clinical performance and consumer experience. High-performing health plans choose NCQA Accreditation because it satisfies many stakeholders: Meets Employer Demands. Many employers especially the Fortune 500 do business only with NCQA-Accredited plans. They and other purchasers want to maximize the value of their health care spending. The National Business Coalition on Health s widely used evalue8 tool captures NCQA Accreditation status and HEDIS/CAHPS scores as an important indicator of a plan s ability to improve health, and health care. Meets Regulator Demands. NCQA Accreditation contains all the key elements that federal law and regulations require for State Health Insurance Exchange plans. Forty states recognize NCQA Accreditation as meeting their requirements for Medicaid or commercial plans; more than a dozen states mandate it for Medicaid. Medicare deems plans with NCQA Accreditation for Medicare Advantage, and the Federal Employees Health Benefit Program accepts NCQA Accreditation. Meets Consumer Demands. Consumers comparison-shop and want to know an insurer s quality when they select a plan. This trend will grow as the number of consumers shopping for coverage in the Exchange market increases. Research in 2012 by NCQA and Consumer Reports shows consumers value accreditation, especially when they know how encompassing NCQA Accreditation is. The rigor and competitive pricing of NCQA s program represent an excellent value for health plans. NCQA publications, user groups and educational programs facilitate the evaluation process. They help plans succeed by making the path to performance-based accreditation accessible and feasible.

6 NCQA-Accredited Plans Perform Better More than 1,000 health plans, covering more than 125 million lives 40% of the U.S. population submit HEDIS data to NCQA, reinforcing HEDIS role as health care s most widely used performance improvement tool. The Centers for Medicare & Medicaid Services requires all Medicare Advantage plans to report HEDIS results, making those plans an excellent laboratory for comparing the quality of plans that have NCQA Accreditation to ones that do not. The chart below shows that NCQA-Accredited plans perform substantially better. All 11 of the nation s 5-star plans in the 2012 Medicare Star Ratings hold NCQA Accreditation. Insurers with high-quality Medicare plans that also offer commercial and Medicaid products tend to be high performers in those markets, too. 34 measures: accredited plans perform better (statistically significant on 17) 8 measures: no meaningful difference 1 measure: nonaccredited plans are better at a statistically significant level For information on how to become an NCQA-Accredited health plan, visit us online at or contact NCQA Customer Support at The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.