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Health Plan Accreditation (HPA) - 2016 Standards

NCQA has released Health Plan Accreditation (HPA) 2016 standards. The updated standards are designed to enhance the core patient protections—for access to clinically appropriate care—that are the hallmark of NCQA programs. 

New Additions to the HPA Standards

Focus on Access to Care

A growing number of health plans offer tailored, or “narrow,” networks. When designed appropriately, this can be good: it allows health plans to increase the quality of each option they provide and to focus on patient experience and access to care. In response, NCQA created Network Management section that provide a more comprehensive assessment of plan networks and focus on specialty areas that are either high volume (e.g., obstetrics/gynecology) or high impact (e.g., oncology). The intent of the NET category of standards is to evaluate whether health plans have enough in-network hospitals and doctors available to members so that all services will be accessible without an unreasonable delay.

More Accurate Information for Members

Consumers rely on the information they find in physician and provider directories to make decisions about which plan to enroll in and where to seek care. Inaccuracies in online or print directories—a long-standing challenge—can interrupt or delay care. The updated NCQA standards require organizations to assess the accuracy of their directories; for example, whether providers have an active network contract, whether physicians are accepting new patients. The standards also call on plans to act on opportunities to improve directory accuracy.

Making Members More Aware

Appropriate and timely coverage decisions are critical to ensuring that patients receive the right care, at the right time. Several high-profile cases that emerged in 2014 raised concerns that health plans were not providing important information to their members about appeal rights. Members did not know how to file an appeal for coverage of care—or if they could file an appeal. The new Utilization Management (UM) standards hold health plans responsible for informing their members of certain coverage details. Increasing the rigor of UM requirements will ensure that plans notify members of their appeal rights, make timely decisions about coverage of care, drugs and services and provide members with accurate reasons for a denial. The standards strengthen key member protections.

Download HPA 2016 Standards

For more information on updates and to view the full NCQA 2016 Health Plan Accreditation standards, download the HP Standards and Guidelines epub.

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HPA Brochure

Click here to download the brochure.