What is NCQA Accreditation?

NCQA accredits a variety of organizations from HMOs to PPOs to Managed Behavioral Healthcare Organizations (MBHOs), and each accreditation program is distinct. The goals of these various accreditation programs, however, is the same; in each case, we conduct an independent, objective review against a set of standards and, based on that review, develop information which we then make publicly available to inform consumers' and employers' enrollment or contracting decisions. The more consumers and employers use our information to help make their decisions, the more of an incentive it gives these organizations to focus on quality. Accreditation is essentially a means of harnessing market pressure to improve the health care system.

Although NCQA's accreditation programs are all quite rigorous, they have been well received by the health care industry. About three-quarters of all HMO enrollees are currently in NCQA-Accredited plans. NCQA's PPO Accreditation program, although still relatively new (it was launched in late 2000) has already enrolled many of the largest PPOs in the country. Among MBHOs, earning NCQA Accreditation is fast becoming the norm.

NCQA Accreditation reviews - which consist of both an on- and off-site component - are conducted by teams of physicians or other health care providers and managed care experts. An independent oversight committee analyzes the teams' findings and the organization's clinical performance (if applicable) and then assigns an overall accreditation outcome.

Earning NCQA Accreditation is not mandatory, so consumer and employer support are essential to encouraging organizations to take part. There is no substitute for a thorough, rigorous external review.

HMO and point-of-service (POS) Plan Accreditation

HMO and POS plans undergoing accreditation are reviewed against more than 60 different standards designed to evaluate the health plan's clinical and administrative systems related to such issues as consumer protection, confidentiality, and customer service. These plans must also report on their clinical performance, using a measurement tool known as HEDIS®, the Health Plan Employer Data and Information Set. These standards and performance measures fall into five broad categories:

Access and Service - Do health plan members have access to the care and service they need? For example: Do patients report problems getting needed care? How well does the health plan follow up on grievances?

Qualified Providers - Does the health plan assess each doctor's qualifications and what health plan members say about their providers? For example: does the health plan regularly check the licenses and training of physicians?

Staying Healthy - Does the health plan help people maintain good health and avoid illness? Do children receive all appropriate immunizations? Do women receive mammograms as recommended?

Getting Better - How well does the health plan care for people when they become sick? How does the health plan evaluate new medical procedures, drugs and devices to ensure that patients have access to safe and effective care?

Living with Illness - How well does the health plan care for people with chronic conditions? Do diabetics, who are at risk for blindness, receive eye exams as needed?

NCQA assigns HMOs and POS one of five possible accreditation levels based on the plan's performance:

• Excellent
  NCQA's highest accreditation outcome is granted only to those plans that demonstrate levels of service and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement. Plans earning this accreditation level must also achieve HEDIS® results that are in the highest range of national or regional performance.
• Commendable
  This accreditation outcome is awarded to plans that demonstrate levels of service and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement.
• Accredited
  Health plans that earn the Accredited outcome must meet most of NCQA's basic requirements for consumer protection and quality improvement.
• Provisional
  Provisional accreditation indicates that a health plan's service and clinical quality meet some, but not all of NCQA's basic requirements for consumer protection and quality improvement.
• Denied
  Denied is an indication that a health plan did not meet NCQA's requirements during its review.

PPO Plan Accreditation

NCQA's PPO Accreditation program focuses on two of the areas addressed by the HMO/POS Accreditation program described above. PPOs don't generally manage health care the same way HMOs do, so the requirements applied to HMOs in the Staying Healthy, Getting Better and Living with Illness categories do not apply to PPOs. PPO standards fall into two categories:

Access and Service - Are patients informed about how to report grievances and does the PPO resolve them quickly and appropriately? Is members' privacy protected? Do members receive complete information about benefits and providers? Is the PPO's network adequate? Are members satisfied?

Qualified Providers -Does the PPO thoroughly assess each doctor's qualification? Can the PPO assure that the organizations checking their doctors' qualifications are doing so accurately?

NCQA assigns PPOs one of four accreditation outcomes:

• Full NCQA's highest accreditation outcome for PPOs is granted to those plans that have excellent programs for quality improvement and consumer protection and that meets or exceeds NCQA's standards. Full accreditation is effective for a three-year period.
• One-Year The PPO has well-established programs for quality improvement and consumer protection and meets most NCQA standards. NCQA has given the PPO plan a list of recommendations and will review the organization again after a year to determine if it qualifies for Full Accreditation.
• Provisional Provisional accreditation indicates that a PPO's service and clinical quality meet some, but not all of NCQA's basic requirements for consumer protection and quality improvement.
• Denied Denied is an indication that a PPO did not meet NCQA's requirements during its review.

The number of people who look to NCQA as a source of information about health plan quality has grown steadily since the accreditation program began. Today, approximately 6,000 visitors a month view our Health Plan Report Card to learn about the accreditation status of area organizations. The Health Plan Report Card is an interactive reference tool that shows the NCQA Accreditation status of HMO, POS and PPO plans that have been surveyed, have a decision pending or have scheduled a survey.

What is New Health Plan Accreditation?

Health plans less than three years old often cannot meet NCQA's regular requirements for Accreditation which ask plans to demonstrate that they have improved over time. These plans may not have enough members and/or simply may not have been in existence long enough to have compiled the data required to demonstrate such improvement. Thus, the NHP program waives this requirement. In all other respects, the NHP program is the same as NCQA's regular MCO Accreditation program. NCQA assigns a designation of 'Accredited' for new health plans meeting these standards.

Plans accredited under this program are listed as 'Scheduled' on the Health Plan Report Card. A full list of accredited New Health Plans can be found here.

welcome | create report card | using results | definitions | methods | participation/statistics | feedback | top

©National Committee for Quality Assurance - 1100 13th Street, NW, Suite 1000, Washington, DC 20005 - (202) 955-3500
contact Webmaster@ncqa.org