Making the Most of Accreditation

NCQA’s State Affairs team works with policymakers to drive health care quality and efficiency by leveraging our accreditation programs.

Supporting a State’s Quality Priorities

NCQA is always ready to help states identify the best way to meet their quality goals.

The approach varies by state: It could mean requiring NCQA Health Plan Accreditation (HPA), using our HEDIS® quality measures to institute a value-based payment arrangement for providers and/or plans, or any number of other possibilities. Regardless, our Public Policy team works closely with state officials to find the right solution.

“There was a big effort for the health care industry to really bring to life a common credentialing system for the collection and verification of practitioner information… We are using a certified Credentialing Verification Organization—they are certified with NCQA. We’ve been working with NCQA since the beginning basically mapping out our program requirements.” Melissa Isavoran, Oregon Health Authority—Office of Health Information Technology.

Supporting States With Medicaid Managed Care

Managed care is an increasingly popular tool for states seeking to standardize quality and control costs in Medicaid.  NCQA programs are widely used to support these objectives, hold private health plans accountable and help plans improve their performance.

Using NCQA Health Plan Accreditation (HPA) to Ensure Quality

Twenty-seven states require that health plans serving their Medicaid population be accredited by NCQA – with seven others accepting our HPA as meeting broad accreditation requirements.

Beyond simply requiring HPA, twelve states use the results of the accreditation process to satisfy federal oversight requirements. Invoking Medicaid’s “non-duplication” provisions (also know as “deeming”) allows states to:

  • Simplify administrative review efforts.
  • Reallocate resources to other priority projects.
  • Demonstrate their commitment to maximizing limited oversight resources.
  • Acknowledge health plans that have gone through the rigorous NCQA accreditation process.

State Spotlight: Read how Tennessee Medicaid (TennCare) is maximizing oversight resources by deeming accredited plans here.

HPA Medicaid Module

In 2018 NCQA added the Medicaid Module to our HPA program. The module enables plans that meet its expanded requirements to seek a broad-spectrum, streamlined review by the state, as allowed under federal Medicaid rules. NCQA’s Medicaid Managed Care Toolkit (see below) includes information on adding the Medicaid Module.

For more information on NCQA’s HPA Medicaid Module, click here.

Medicaid Managed Care Toolkit

Each year, NCQA publishes the Medicaid Managed Care Toolkit showing states what NCQA Health Plan Accreditation standards can be mapped to external quality review activities.

Slightly more than 75% of NCQA standards overlap with mandatory external quality review activities. As noted above, plans that have met these standards through NCQA accreditation may be deemed as complying with federal requirements.

Download the toolkit here.

States and LTSS

States are increasingly looking to managed care and value-based purchasing to meet the needs of Long-Term Services and Supports (LTSS) recipients.  More than 5 million people receive LTSS through the Medicaid program.

NCQA has developed two programs that work to improve the quality of care for this population.  Already a number of states are requiring participants in their LTSS initiatives to go through one or both of these programs.

Health Plans: Long-Term Services and Supports (LTSS) Distinction for Medicaid Managed Care Plans.

LTSS Distinction provides a standardized framework for holding plans and managed behavioral healthcare organizations (MBHO) accountable for managing and coordinating LTSS.

What’s the value to states?

  • Standardizes the model of care for plans and MBHOs that manage and coordinate LTSS.
  • Complements existing NCQA Health Plan Accreditation requirements.
  • Aligns with LTSS provisions in the 2016 Medicaid managed care rule.
  • Enhances state Medicaid managed care quality strategy efforts.
  • Demonstrates a commitment to integrating care and improving outcomes for the Medicaid population.

State Spotlight: Read more on how Kansas is ensuring quality for LTSS here. 

For more information on the LTSS Distinction, visit our program page here.

Case Management for Long-Term Services and Supports (CM-LTSS) for Community-Based Organizations.

States are raising the bar to hold organizations such as Area Agencies on Aging and Other Community-Based Organizations accountable for coordinating and managing care for the population that needs LTSS.

What’s the value to states?

  • Standardizes the model of care for managing LTSS.
  • Promotes efficiency and improves outcomes.
  • Prepares organizations for managed care.
  • Demonstrates an organization’s readiness to be a trusted LTSS partner.
  • Drives integrated care.
  • Aligns with LTSS provisions in the 2016 Medicaid managed care rule.
  • Enhances a state’s quality strategy and value for contracting with plans.

Find more details on the Case Management for LTSS Accreditation here.

Other Uses of Accreditation

Plan Oversight & Contracting: Insurance & Public Employee Benefits Agencies

Thirty-three states in the commercial market—including Departments of Insurance and Public Employee Benefit Programs—require or recognize NCQA Health Plan Accreditation to promote high quality care for consumers. See the map of states and a full list of state requirements here.


Public Reporting: Making Informed Choices

States and the federal government use accreditation and HEDIS® in their report cards to help people make apples-to-apples comparisons when choosing a health plan. It is also being used by states and Medicare to adjust payment to reward plans for quality.

Currently 41 states have HEDIS reporting and all Medicare Advantage plans report their performance. Results are included in Star Ratings on the quality of each plan.

Results show that NCQA-Accredited plans perform better. Our plans deliver better care at a statistically significant level on several critical measures, including access to care, diabetic blood sugar control, cholesterol and blood pressure control, breast and colorectal cancer screening, and counseling enrollees on nutrition and physical activity.


Medicare Advantage Deeming

Medicare also has authority to use a plan’s NCQA accreditation status as proof that a plan has met program requirements in areas like quality improvement, access to care and privacy. This process, known as deeming or non-duplication, allows plans and the federal government to avoid duplicative reviews and focus on other enforcement priorities.

We are now working to apply this authority to Medicare Advantage Special Needs Plans (SNPs) through a program in which NCQA could verify for Medicare that the plans are implementing the models of care their enrollees need.

  • Save

    Save your favorite pages and receive notifications whenever they’re updated.

    You will be prompted to log in to your NCQA account.

  • Email

    Share this page with a friend or colleague by Email.

    We do not share your information with third parties.

  • Print

    Print this page.