Today, NCQA has two major ways people can identify high quality health plans: Health Plan Accreditation and Health Plan Ratings. The scoring methodology in Health Plan Ratings and in Accreditation statuses are different. Employers, states and consumer advocates gave feedback to NCQA that this can be confusing and they 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 will simplify the scoring methodology for Accreditation.
This means NCQA is updating scoring for Health Plan Accreditation and adjusting the status levels displayed upon receiving accreditation.
How Will Plans Earn Accreditation?
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). Plans will still be evaluated based on standards and HEDIS/CAHPS reporting. Starting in 2020:
- To earn Accreditation, plans must:
- Meet at least 80% of applicable points in each standards category.
- Submit HEDIS/CAHPS reporting during the reporting period after their first full year of Accreditation.
- Submit HEDIS/CAHPS annually thereafter.
How Will Standards Be Scored?
- To earn points in each standards category, plans will be evaluated on the factors satisfied in each applicable element and will earn Met, Partially Met or Not Met for each element. To help simplify scoring, elements will be worth 1 or 2 points. :
- Met = Earns ALL applicable points.
- Partially Met = Earns HALF of applicable points.
- Not Met = Earns NO points.
- Because elements start as whole numbers, and plans either receive all, half or no points for each, scoring is easier. Instead of dealing with varied numbers and decimal places, organization scores will be 0, 0.5, 1 or 2.
- Within each standards category, the total number of points is added. Plans earn accreditation status based on how they score on each standards category. If the plan earns:
- 80%+ of applicable points: The plan earns accreditation.
- Less than 80% or greater than or equal to 55% of applicable points: The plan earns accreditation and a Provisional status.
- Less than 55% of applicable points: The organization can be denied accreditation.
Once that status is earned, plans will begin reporting HEDIS/CAHPS on an annual basis starting the year after they earn accreditation. Learn more about the HEDS/CAHPS reporting timeline.
Product Line Level Scoring
This change affects organizations that seek Accreditation for multiple product lines. Previously, there were several elements for which plans would submit evidence to NCQA by product line, but the plan would be awarded a cumulative score across product lines instead of a score for each product line. Starting with Health Plan Accreditation the 2020 standards, NCQA will review and score certain elements by product line. NCQA will report scores for standards by product line instead of averaged across product lines.
What does this mean for a plan?
- If a plan seeks accreditation with one product line, nothing will change from what is done today.
- For organizations that bring through plans with multiple product lines:
- The plan will now have to show evidence or samples by product line (e.g. Medicare, Medicaid, Commercial/Exchange) for some select elements (Note: This is not for all elements, just select ones).
- Where applicable, the plan will be scored by product line at the element level and element scores will be added up for each standards category to produce a distinct score for each product line. (Note: Previously plans received an average score for a plan that included all product lines).
- In addition, any corrective action plans (which today are for the entire plan across all product lines) will be targeted to the product line where the score indicates a corrective action plan is needed.
- This helps clarify to plans, states and others where areas of concern lie, and helps plans better focus on areas that need improvement.
How will NCQA distinguish quality between plans?
Today, NCQA has two different ways to look at a health plan’s quality: the status a plan earns as part of accreditation (e.g. excellent, commendable or accredited) and a numerical rating as part of annual health plan ratings released each September. NCQA received feedback that these different methodologies can be confusing for consumers, employers and others trying to discern a health plan’s quality.
As a result, NCQA is eliminating the Excellent and Commendable status levels and will instead use the Health Plan Ratings to distinguish quality. Accredited plans will earn ratings after they submit HEDIS/CAHPS reporting and can advertise the rating alongside their accreditation seal. Read more about ratings methodology.
NCQA is also moving from a numeric rating (1–5) to a “star” rating system (1–5 stars). Ratings will be released in September of each year, starting with September 2020 (using the June 2020 HEDIS data). NCQA did an analysis of current statuses compared to projected future scores. The comparison is roughly as follows:
|Current Status||Projected Stars|
Until an organization receives a star rating, organizations that earn an accreditation will display the seal with the type of accreditation they received (Accredited, Provisional or Interim).
Plans that are already Accredited and submitting HEDIS will continue submitting HEDIS/CAHPS annually. Plans that earn First or Interim Accreditation for the first time will be required to submit HEDIS/CAHPS during the first reporting period after their first full year of Accreditation. Learn more about changes to HEDIS reporting for plans seeking Accreditation for the first time.