The National Committee for Quality Assurance

FACT SHEET

The National Committee for Quality Assurance “Gold Standard” for Health Plan Accreditation

NCQA health plan Accreditation is the most rigorous process for evaluating the quality of care and customer service that insurers provide. It is more comprehensive and specific than accreditation from other organizations.

What makes NCQA the gold-standard in Health Plan accreditation?  We are the largest accreditor with over 136 million covered lives.  Our “performance-based” program rates the actual quality of care and service plans provide, not just whether they have policies and procedures that could promote quality.  We publicly report our results in national publications like Consumer Reports.  Consumer protections are incorporated throughout.

By verifying, scoring and publicly reporting results of standardized measures each plans’ quality of care and service, we help consumers and other purchasers make apples-to-apples comparisons among plans. We also give plans a strong incentive for continuous improvement that provides better value for America’s health care dollars. Other accreditors have do not have experience with this value-driving, “performance-based” accreditation. NCQA updates the program annually, adding new measures and more challenging standards to stay ahead of the curve on best practices in quality.

More than 600 health plan products have earned NCQA’s prized Accreditation. At least a dozen states require NCQA Accreditation for Medicaid plans and another 31 recognize NCQA- Accredited plans as meeting key state quality and consumer protection requirements. The federal government recognizes NCQA Accreditation for both federal employee and Medicare plans. NCQA’s Accreditation also is by far the most sought after among health plans that will offer coverage on State Health Insurance “Marketplaces” or Exchanges.

Performance-Based Scoring: NCQA requires plans to report HEDIS® clinical quality measures and CAHPS® patient experience measures. 1 These are the most widely used and respected tools for assessing quality of care and services in health care. We also have strict auditing requirements to ensure accuracy of results – plans cannot simply “check a box.” We

1 HEDIS® is a registered trademark of NCQA. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.

© 2013 National Committee for Quality Assurance. All rights reserved. 1 score the results based on both national and regional benchmarks to allow direct comparisons among plans. Publicly Reporting Results: NCQA publicly reports accreditation results in detailed Health Plan Report Cards.2 Consumer Reports publishes NCQA’s health plan rankings for its discriminating readers. Less rigorous programs do not have experience rating clinical performance and customer service that allows apples-to-apples comparisons of plans’ value.

Transparent and Rigorous Methodology: NCQA Accreditation distinguishes performance through multiple levels of accreditation (Excellent, Commendable, Accredited). We accredit and report performance by both plan products (HMO, HMO/POS, PPO) and product lines (Commercial, Medicare, Medicaid, Exchanges). We regularly updated our Health Plan Report Cards on plan performance in five categories: “Staying Healthy,” “Getting Better,” “Living with Illness,” “Qualified Providers” and “Access to Service.” Users can search the Report Card by both insurer and state. Other accreditation programs only report whether a plan has accreditation without reporting on quality or facilitating comparisons.

Comprehensive Review of Health Plan Processes: NCQA further requires plans to meet system and process standards that are essential for quality care and consumer protection. These standards address quality improvement, provider credentialing, utilization management, member rights and responsibilities and patient information programs. We conduct detailed reviews to verify that plans have consistently enforced these critical consumer protections and do not merely have them on paper.

We developed our standards based on input from consumers, physicians, public and private purchasers, insurers and quality researchers and update them each year. The annual updating process includes public comment and review by several multi-stakeholder governing committees with consumer, employer, public sector and health plan experts. By continuously updating our standards we challenge health plans to further improve quality. We also go beyond other programs by scoring important services that promote quality, such as continuity and coordination of care, case management, disease management and wellness programs.

Consumer Protections Are Incorporated Throughout: Strong consumer protections permeate NCQA Accreditation requirements. They include requirements for accurate marketing, protecting member rights and privacy, continuously working to improve the quality of care and customer service, sound coverage decisions, access to care, and a timely, fair appeals process. (For more details, please see “Consumer Protections in NCQA Health Plan Accreditation” at http://www.ncqa.org/Newsroom/ResourceLibrary.aspx.)

So clearly, not all health plan accreditation programs are created equal. NCQA’s rigorous Accreditation is the “gold standard” because we require more of plans and therefore achieve more. The results help protect consumers, provide for informed plan decisions and light a clear

2 http://www.ncqa.org/ReportCards/HealthPlans.aspx

© 2013 National Committee for Quality Assurance. All rights reserved. 2 path for continuously improving the quality of health care. For more information please contact NCQA Vice President Sarah Thomas at (202) 955-5162 or [email protected].