Standards in this content area build upon existing chronic care and disease management standards in the MCO Accreditation program. Therefore, only organizations that currently hold or are applying for NCQA MCO Accreditation are eligible to apply for distinction in the Care Management and Health Improvement content area. These standards emphasize wellness, chronic care and complex case management.

NCQA evaluated potential Care Management and Health Improvement 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?

Care Management and Health Improvement focuses on four areas:

Wellness and Prevention

• Do members have access to a health information line?
• Are members identified for wellness activities?
• Does the organization provide targeted follow-up for members based on conditions or risk factors?
• Are incentives used to encourage members' health?

Managing Members With Chronic Conditions

• Are members identified and engaged in disease management programs?
• Are members satisfied with disease management services?
• Is member health information integrated by the plan to facilitate continuity of care?

Complex Case Management

• Are members identified for case management services?
• Does the plan have a process to assess and support the needs of members requiring case management?
• Are members satisfied with case management services?
• Does the plan measure the effectiveness of its case management programs?