Health Plan Accreditation 2020: Reduction in Total Requirements

NCQA regularly considers retiring requirements that have become standard practice or are no longer in line with market needs. For 2020, NCQA retired 22 elements and 7 factors. Some retired elements were duplicative; some were no longer necessary because they had become best practices.

We also reduced the number of elements that require the plan to submit evidence at renewal. Combined with the retired elements, most plans will experience approximately a 34 percent reduction in elements that require evidence at renewal by focusing on elements showing implementation of policies and quality improvement.

This helps reduce the burden of preparation while maintaining strong consumer protections.

Information for Medicaid Plans

Medicaid plans will still have a reduction in total requirements, but will be required to show evidence so Accreditation can still meet some CMS oversight requirements.

  • CMS has certain requirements for Medicaid plans that must be reviewed on a regular basis by states.
  • Some states deem NCQA Accreditation, which means they use NCQA Accreditation as part of their oversight and compliance.
  • As a result, for Medicaid plans, there are several requirements retired as part of the standards update for health plans Accreditation, or that are not reviewed as part of renewal, that will still be reviewed for Medicaid plans, as they are CMS requirements that need to be reviewed in order for deeming to occur. This helps assure that NCQA still supports Medicaid plans and helps them meet CMS Managed Care requirements.
  • These include:
    • The following elements were retired, but moved to the Medicaid Module for plans that seek to earn that status:
      • QI 2B: Informing Members
      • UM 4G: : Affirmative Statement About Incentives.
    • The following elements will still be reviewed at renewal for Medicaid plans only.
      • QI 1A: QI Program Structure (formerly QI 1, element A, factors 1-5, 7)
      • QI 2A: Practitioner Contracts (formerly QI 3A)
      • NET 5A: Physician Directory Data (formerly NET 6A)
      • NET 5B: Physician Directory Updates (formerly NET 6B)
      • NET 5F: Hospital Directory Data (formerly NET 6G)
      • NET 5G: Hospital Directory Updates (formerly NET 6H)
      • UM 1A: Written Program Description
      • UM 4A: Licensed Health Professionals
      • UM 4B: Use of Practitioners for UM Decisions
      • UM 8A: Internal Appeals
      • CR 1A: Practitioner Credentialing Guidelines
      • CR 1B: Practitioner Rights
      • ME 1A: Rights and Responsibilities Statement (formerly RR 1A)

NCQA will be retiring the following requirements in Health Plan 2020:

Standard/ElementWhat’s Retiring?
QI 2, Element B: Informing MembersElement B
QI 4, Element A: Member Services Telephone Access
QI 4, Element B: Behavioral Healthcare Telephone Access
QI 4, Element G: Assessing Experience With the UM Process
Elements A, B, G
QI 5, Element D: Transition to Other Care, factor 2Factor 2
PHM 4, Element A: Health Appraisal Components
PHM 4, Element B: Health Appraisal Disclosure
PHM 4, Element C: Health Appraisal Scope
PHM 4 Element D: Health Appraisal Results
PHM 4, Element E: Health Appraisal Format
PHM 4, Element G: Health Appraisal Review and Update Process
PHM 4, Element I: Usability Testing of Self-Management Tools
PHM 4, Element J: Review and Update Process for Self-Management Tools
PHM 4, Element K: Self-Management Tools Format
Elements A–E, G, I, J
PHM 5, Element F: Experience With Case ManagementElement F
MEM 2, Element A: Pharmacy Benefit Information—Website, factor 6, factor 7
MEM 2, Element B: Pharmacy Benefit Information—Telephone, factor 6, factor 7
Factors 6 and 7
MEM 3, Element A: Functionality—WebsiteFactor 1
MEM 4, Element A: Supportive TechnologyElement A
NET 4, Element A: Network Design Criteria for Practitioners
NET 4, Element B: Network Design Criteria for Hospitals
Elements A, B
NET 6, Element E: Physician Information Transparency
NET 6, Element I: Hospital Information Transparency
NET 6, Element K: Usability Testing, factor 1
Elements E, I

Factor 1
UM 5, Element A: Timeliness of Nonbehavioral Healthcare UM Decision Making
UM 5, Element C: Timeliness of Behavioral Healthcare UM Decision Making
UM 5, Element E: Timeliness of Pharmacy UM Decision Making
Elements A, C, E
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