Health Plan Accreditation Requirements

NCQA Health Plan Accreditation evaluates organizations providing managed health care services. Your organization must meet the program criteria to pursue accreditation.

FOCUS AREAS TO ENSURE HIGH QUALITY

NCQA Health Plan Accreditation requirements guide organizations to deliver high quality care that aligns with areas most important to states, employers and consumers.
Requirements cover these key areas:

  • Quality improvement.
  • Population health management.
  • Network management.
  • Utilization management.
  • Credentialing and recredentialing.
  • Members’ rights and responsibilities.
  • Member connections.
  • Medicaid benefits and services.

To see all program requirements, get the Standards & Guidelines document.

REQUIRED ORGANIZATION SERVICES

The standards are designed for organizations providing managed health care services but are not specific regarding the type of managed care services.

IS MY ORGANIZATION ELIGIBLE?

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.

RELATED PROGRAMS

NCQA offers several related programs for organizations eligible for the Health Plan Accreditation. Each program helps organizations improve their operations and initiatives in targeted areas and demonstrate their commitment to quality.
The programs are: Long-term Services and Supports Distinction and Multicultural Health Distinction.

LONG-TERM SERVICES AND SUPPORTS DISTINCTION

NCQA offers a Long-Term Services and Supports (LTSS) Distinction for organizations who provide managed health services and coordinate social services for LTSS.

The standards provide a framework for organizations to deliver effective person-centered care that meets people’s needs and aligns with state requirements.

Learn more about NCQA LTSS Distinction for Health Plans

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MULTICULTURAL HEALTH CARE DISTINCTION

NCQA Distinction in Multicultural Health Care evaluates how well organizations identify needs and provide care to groups with different racial, ethnic and cultural backgrounds, including how those organizations provide culturally and linguistically sensitive services and work to reduce health care disparities.

The NCQA standards are a roadmap for how and organization can deliver the high-quality, care.

Learn more about NCQA Multicultural Health Care Distinction

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