Health Plan Accreditation FAQs
Below are some of the most frequently asked questions about NCQA Health Plan Accreditation. If you don’t see what you’re looking for below, you can search NCQA’s database of additional common questions for Medicare, Medicaid and commerical plans or marketplace plans. Or ask a question through My NCQA.
What is Health Plan Accreditation?
NCQA Health Plan Accreditation is widely recognized, evidence-based program in the industry dedicated to quality improvement and measurement. It provides a comprehensive framework for organizations to align and improve operations in areas that are most important to states, employers and consumers. It’s the only evaluation program that bases results on actual measurement of clinical performance (i.e., HEDIS measures) and consumer experience (i.e., CAHPS measures).
How does Health Plan Accreditation help my organization?
- Use the NCQA Health Plan Accreditation standards to perform a gap analysis and determine improvement areas. They provide a framework for implementing evidence-based, best practices help plans improve in areas of:
- QI process.
- Population health management.
- Practitioner network and access to care.
- Utilization management processes.
- Credentialing and recredentialing processes.
- Members’ rights and responsibilities.
- Member connection.
- Medicaid service requirements.
- Satisfy state requirements and employer needs. The standards align with many state requirements.
What are Health Plan Accreditation requirements?
NCQA standards are a roadmap for improvement—organizations use them to perform a gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. Standards help plans in:
- Quality Management and Improvement.
- Population Health Management.
- Network Management.
- Utilization Management.
- Credentialing and Recredentialing.
- Members’ Rights and Responsibilities.
- Member Connections.
- Medicaid Benefits and Services.
Where can I find the Standards and Guidelines?
Find the Standards and Guidelines document in the NCQA Store.
What organizations are eligible for Health Plan Accreditation?
Any organization that provides managed health care services may apply for the NCQA Health Plan Accreditation if it meets the following criteria:
- Operates under an insurance license (e.g., HMO, POS, PPO, EPO), and
- Issues a contract for insurance for a defined population or contracts with an employer to provide managed care services for a self-insured population, and
- Provides services through an organized delivery system that includes ambulatory and inpatient health care sites, and
- Performs functions addressed in the standards (quality improvement, care coordination, utilization management, credentialing, member rights and responsibilities), either directly or through a service agreement, and
- Has a process for monitoring, evaluating and improving the quality and safety of care provided to its members, and
- Reports audited HEDIS results for designated HEDIS measures and CAHPS ratings and composites, as required for the selected Evaluation Option.
What is the process for earning Health Plan Accreditation?
The first step to earning accreditation is a discussion with an NCQA program expert. Purchase and review the program resources, conduct a gap analysis and submit your online application.
Align your organization’s processes with the standards. NCQA conducts the survey and determines your accreditation status within 30 days of the final review.
See a step-by-step process.
What is the price for Health Plan Accreditation?
Pricing is based on multiple factors. Obtain full pricing information by submitting a request through My NCQA.
How long does it take to earn Health Plan Accreditation?
The typical evaluation timeframe is 12 months from application submission to decision, depending on an organization’s readiness. Some organizations may already be working within NCQA guidelines.
How do I get started?
If you are not currently accredited and want to learn more, contact NCQA. If you are currently accredited and want to talk to someone about your status or about renewing or adding accreditations, submit a question through My NCQA.
Where can I find information to help me get started?
- Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation.
- Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review.
- Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organization’s survey readiness—the tool calculates your potential survey score.
What other organizations have earned Health Plan Accreditation?
Over 1,000 health plan products have earned NCQA Health Plan Accreditation. See the NCQA Report Card for a directory of accredited organizations.