The Member Connections standards are the first of three content areas of the Quality Plus standards. Standards in the areas of Physician and Hospital Quality and Care Management and Health Improvement were released for public comment in the spring of 2005.

Member Connections standards assess how effectively an organization interacts with its members via the Web and telephone to make sure they understand and know how to use their benefits, have access to self-management tools for certain conditions and can check on the status of their claims. The degree to which a plan effectively does these things and makes it easy and convenient for members to get answers to related questions can substantially impact member satisfaction.

In traditional as well as newer forms of managed care, members are taking on more and more responsibility to make decisions about their own health care. This is a positive trend, but only in so far as members have the information they need to make informed decisions. These standards are designed to help ensure that they do.

NCQA evaluated potential Member Connections standards against a strict set of criteria to determine whether or not to include them in the draft set of standards.

Standards criteria were then evaluated against the following questions:

• Does the standard promote state of the art activities or processes?
• Do pilot tests, interviews and public comment demonstrate that organizations have the capability to perform the activity? Do some organizations currently perform the activity?
• Does evaluation and scoring recognize that many of these activities are in their infancy? Does the standard encourage innovation and advancement in an orderly manner?
• Do the standards recognize the need to promote accessibility and availability of services to sicker populations?
• Is there evidence of serious market expectations from purchasers on the standard?
• Are the requirements unique to the Quality Plus program? Do they cover activities that go above and beyond existing Accreditation requirements?
• Can NCQA survey the standard objectively?
• Can the entire content area be surveyed efficiently, making maximum use of technology?

Member Connections focuses on four areas:

Support and Administration

• Do members have the information they need to understand and use the plan’s services?
• Can they change doctors or order enrollment cards on the plan’s Web site?
• Can they find out how much a given procedure or therapy might cost?
• How do members rate the plan’s services?

Claims

• Can members easily track claims?
• Is tracking available via the Web?
• How quickly are claims processed?
• Are claims processed accurately?

Pharmacy Benefits

• Do members have access to comprehensive information about their pharmacy benefits and how to use them?
• Can they get cost information about specific drugs by calling or visiting the plan’s Web site?
• Is information provided about drug-drug interactions and generic substitutions?
• Is it possible to order a refill online or through the mail?

Self-management

• Does the plan help members conduct a health risk appraisal?
• Does the plan offer interactive tools on its Web site related to issues such as smoking cessation, exercise, immunizations and screenings?
• Are evidence-based guidelines the basis for such tools?
• How often are the tools tested and updated?