For the purposes of Accreditations in Health Outcomes and Community-Focused Care, a health plan that is seeking accreditation that provides both payor and provider functions (i.e., direct medical or behavioral patient care) is considered both a payer and a care delivery organization. “Direct medical or behavioral patient care” is not intended to include case management for the purposes of Accreditations in Health Outcomes and Community-Focused Care.
A health plan that provides direct medical or behavioral patient care must also meet the following requirements that apply only to care delivery organizations:
- HO 2, Element E.
- HO 2, Element H, factor 5.
- HO 2, Element I, factor 5.
- HO 2, Element J, factor 5.
- HO 4, Element A.
- HO 4, Element B.
- HO 5, Elements D and E.
A health plan that does not provide direct patient care is not considered a care delivery organization. It is considered a payer only. The requirements listed above that apply only to care delivery organizations would not apply to a health plan that is a payer only.
