NCQA Comments on Proposed 2024 ACA Exchange/Marketplace Rules

NCQA urges CMS to require Health Equity Accreditation for Exchange plans

January 30, 2023

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore MD 21244

Attention: CMS-9899-P Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2024

Dear Administrator Brooks-LaSure:

The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the 2024 Notice of Benefit and Payment Parameters (NBPP) for Qualified Health Plans (QHP).

NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation, clinician quality and measurement programs. We are a national leader in quality oversight and a pioneer in digital quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate their journey toward an equitable, digitally enabled health care system. Our mission to improve the quality of health for all Americans, with an intentional focus on health equity and support for meaningful value-based payment models, propels our daily work.

In our response to last year’s NBPP, we expressed our appreciation to CMS for including an RFI to seek “input on requiring QHP issuers to obtain the National Committee for Quality Assurance Health Equity Accreditation in addition to their existing accreditation requirements;” and we were encouraged to see, in the final rule summary, “commenters supported CMS’ suggestion for QHP issuers to obtain a health equity accreditation, and some specified support for the National Committee for Quality Assurance Health Equity Accreditation to encourage issuers to take meaningful steps to advance health equity.”

NCQA’s Health Equity Accreditation comprises six foundational standard categories on which health care organizations are surveyed and scored:

  1. Organizational Readiness. The organization is committed to health equity by building a diverse and inclusive staff.
  2. Race, Ethnicity, Language, Gender Identity and Sexual Orientation Data. The organization gathers data on race, ethnicity, language, gender identity and sexual orientation using standardized methods.
  3. Access and Availability of Language Services. To effectively communicate with patients, the organization provides materials and services in languages patients use and understand.
  4. Practitioner Network Cultural Responsiveness. The organization’s practitioner network is capable of serving its diverse membership and is responsive to member needs and preferences.
  5. Cultural and Linguistically Appropriate Services (CLAS). The organization continually improves its services to meet the needs of multicultural populations.
  6. Reducing Health Care Disparities. The organization uses data on race, ethnicity, language, gender identity and sexual orientation to assess the existence of disparities and focus on improving provision of CLAS and decreasing health care disparities.

We encourage CMS to formalize the requirement for QHPs to earn NCQA Health Equity Accreditation. National accreditation standards can support the administration’s interest in updating conditions of participation and clinical quality standards to ensure organizations advance culturally competent, person-centered care requirements. We believe there is universal support to use CMS-approved Accrediting Organizations to advance equitable health outcomes, and we are proud of the success and evolution of NCQA’s Health Equity Accreditation program.

Despite assertions by some commenters in last year’s RFI, we want to clarify that Health Equity Accreditation is not a new program. We rebranded and updated our Multicultural Health Care Distinction program (based on the HHS Office of Minority Health’s CLAS Standards), which since 2010 has been a framework for health care organizations to close inequitable health outcomes.

Since the program’s release, more than 100 organizations across the country have earned Health Equity Accreditation (or its predecessor), and it continues to garner exceptional interest from state and federal policymakers. Ten state Medicaid programs require the program in managed care contracts, and QHP exchanges in California and Washington, DC, require Health Equity Accreditation (or its predecessor) for all issuers. Since our response to the NBPP last year, the program has experienced a 100% growth in both new organizations and state requirements.

Consumers, CMS state partners and many health plans are in favor of CMS requiring NCQA’s Health Equity Accreditation. This requirement would advance both CMS’s Strategic Plan and National Quality Strategy to advance and embed health equity into CMS programs. The table below contains organization’s comments from last year’s RFI.

Families USA
Families USA supports the Department’s proposed requirement for QHPs to meet standards for equity as part of their accreditation review. NCQA’s Health Equity Accreditation is an example of a tool that would standardize health equity efforts across all QHPs and formalize structures, processes, and goals for identifying and addressing health disparities. The Health Equity Accreditation incorporates Multicultural Healthcare Certification that prioritizes the provision of culturally competent care, including culturally and linguistically appropriate services. The Health Equity Accreditation also requires QHP issuers to improve internal equity in their organization, with measures to strengthen organizational diversity, equity, and inclusion and to reduce bias. Furthermore, the Accreditation standards emphasize collecting gender identity and sexual orientation data and reporting HEDIS measures that are stratified by all applicable categories of race and ethnicity. These are all critical steps towards achieving a more equitable health system and making sure that QHP issuers are centering equity in their models.
UnitedHealth Group
CMS is seeking input on ways to promote health equity and ensure that all communities have equal access to needed health services. UHC and its parent company UnitedHealth Group (UHG) support such initiatives and we look forward to continuing our dialogue with CMS on this important issue. In particular, we welcome NCQA’s new Health Equity Accreditation as a means to measure and demonstrate the impact of our programs in identifying and addressing health disparities and advancing health equity.
Covered California
Covered California is contractually requiring all QHP issuers to obtain NCQA Multicultural Health Care (MHC) Distinction (now Health Equity Accreditation) by 2023, with incentives for early attainment by December 2022 and potential financial consequences for failing to achieve by year-end 2024. In 2020, Covered California contracted with Health Management Associates (HMA) to evaluate the benefits and drawbacks of requiring the NCQA MHC Distinction for all issuers to build health equity capacity. HMA concluded that requiring the MHC Distinction would support the creation of a necessary and consistent infrastructure for improving culturally and linguistically appropriate services and narrowing disparities across QHP issuers. Achieving Health Equity Accreditation can impact issuers’ resource allocation (including staffing, funding, and other priorities) to deliberately address disparities and health equity, increasing infrastructure and reinforcing organizational commitment to this work.

Additionally, NCQA recommends that in future proposed rules, CMS seek industry feedback on requiring NCQA’s Health Equity Accreditation Plus for QHP issuers. This program builds on Health Equity Accreditation, its prerequisite, by requiring organizations to also collect data on social needs and upstream social risks of the communities they serve, and to make data-driven decisions to improve members’ access to and experience with community-based partnerships and resources, with the goal of improving outcomes.

In 2021 and 2022, two health care systems (Novant Health, Hennepin Healthcare) joined seven health plans as inaugural participants to achieve Health Equity Accreditation Plus. Health Equity Accreditation and Health Equity Accreditation Plus encourage alignment across the care continuum—they are available to provider groups, health systems, hospitals, ACOs, health plans and more.

Thank you for the opportunity to comment. We remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system. We welcome a discussion on our experience and recommendation to require QHPs to obtain NCQA’s Health Equity Accreditation. If you have any questions, please contact Eric Musser, Assistant Vice President of Federal Affairs, at (202) 955-3590 or at


Margaret E. O’Kane

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