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Health Plan Accreditation: 2020 Update

Every year, NCQA adjusts its standards and guidelines in response to feedback from plans, policy makers, providers, patients and others. In 2019 we also updated our scoring methods and how we award Accreditation. The result is a more straightforward and transparent process that maintains strong consumer protections.

We focused on the following areas for Health Plan Accreditation 2020:

  1. Align Health Plan Accreditation and Health Plan Ratings. We improved the methodology used to evaluate and communicate health plan performance on clinical (HEDIS®) and patient experience (CAHPS®) measures, making it easier to understand how well a plan performs.
  2. Simplify scoring and improve transparency. We transitioned scoring from a complex points system to simpler scoring thresholds.
  3. Strengthen consumer protections. We strengthened oversight in Utilization Management (UM) and Credentialing (CR) standards by adding new requirements and elements as “must-pass.”
  4. Reduce the paperwork burden on health plans. We retired 22 elements and reduced the number of elements for which plans must show evidence during renewal. We’ve done this while maintaining a focus on policy implementation and core consumer protections.
  5. Survey tool and process improvements. NCQA is enhancing the survey tool and simplifying the Accreditation process to improve the customer experience.

You can purchase the standards here.

More Information

Updates to Scoring, Accreditation Statuses and Report Cards

Before the 2020 standards year, 50 percent of the points organizations earn toward Accreditation was based on standards (processes, policies and procedures) and 50 percent was based on measures (HEDIS®/CAHPS® reporting). NCQA also releases yearly Health Plan Ratings to highlight strong performance in quality and patient experience.

Because the scoring methodology in Health Plan Ratings and in Accreditation statuses are different, scoring can be confusing. Employers, states and consumer advocates are looking for one source that is the authority on how plans perform.

Therefore, beginning with Health Plan Accreditation 2020 and the 2020 HEDIS reporting year, Health Plan Ratings and Accreditation will align. This will improve consistency between Health Plan Ratings and Accreditation and create a simpler and more transparent scoring methodology for Accreditation. Learn more.

Reduction in Total Requirements

As a way to reduce burden on health plans, NCQA routinely retires requirements that have become standard practice or are no longer in line with market needs. For 2020, NCQA retired 22 requirements and reduced the number of requirements for which plans need to submit evidence at renewal. Learn more.

New Requirements/Consumer Protections

In response to feedback from states and other stakeholders, NCQA identified requirements that will be must-pass elements starting in 2020. These elements, in the Credentialing and Utilization Management categories, will strengthen consumer protections and help organizations manage their procedures and risk. We will also begin reviewing UM denials by product line. Learn more.

Reporting Timetable

To strengthen our quality measurement, NCQA modified the timetable for HEDIS® and CAHPS® reporting for organizations seeking initial Accreditation. Organizations that are already Accredited and reporting HEDIS/CAHPS will see no change. Learn more.

Survey tool and process improvements.

NCQA is updating the survey tool and simplifying the Accreditation process to improve the customer experience. NCQA is enhancing the application, making file reviews more efficient, improving document management and creating a unified view for linked licenses and Single Site Multiple Entity (SSME) Surveys. Learn more.

Learn More at Health Care Quality Congress

Each year, the Health Care Quality Congress offers an accelerated familiarization program on the annual new releases of improvements to NCQA Accreditation standards and guidelines. The meeting is your first opportunity after the release of the Health Plan Accreditation standards and HEDIS measures to ask questions, learn about the latest developments directly from experts and develop your organization’s ability to offer high-quality, value-based care. Register today.

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