- 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.
HP 2020