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New NCQA Scoring- What Health Plans Should Know

Starting in 2020, a systemic shift will change the way health plans prepare for, and are scored, during National Committee for Quality Assurance (NCQA) accreditation. With the focus on quality of care, this transition means keeping up with new requirements is important now more than ever.

Health plans are graded by employers, regulators and consumers on the quality of care they provide for their members. The best way for a health plan to achieve the highest level of quality and increase the likelihood of desired health outcomes for its members, is through health plan accreditation.

Health plan accreditation is becoming increasingly more important as the focus on quality of healthcare sharpens. By definition, accreditation is a comprehensive evaluation process in which a healthcare organizations’ systems, processes and performance are examined by an impartial, external organization to ensure business is conducted in a manner that meets predetermined criteria and is consistent with national standards. Ultimately, a health plan’s accreditation status provides an impartial opinion about its quality.

NCQA Health Plan Accreditation is widely recognized as the stamp of approval for health plans and is built on flexible, yet rigorous, standards. Health plans are scored equally on clinical performance, consumer experience, and a set of standards used to measure performance. NCQA publicly reports quality results which allows for a fair and “apples to apples” comparison among plans.

In 2019, and previous years, the scoring for organizations seeking NCQA accreditation included organizations earning up to 50 points for Standards, including structure and process, 50 points for Healthcare Effectiveness Data and Information Set (HEDIS), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) reporting which required 65 or more points for accreditation.

Beginning with the 2020 Standards and HEDIS reporting year, NCQA changes will impact health plans going through a first accreditation process as well as those undergoing reaccreditation. Surveys changes include:

  • Standards – Plans must now meet at least 80 percent of applicable points in each standard category. A total amount of points will no longer be assigned for accreditation as in years past.
  • HEDIS and CAHPS reporting – Plans must submit reports after the first full year of accreditation and annually thereafter.
  • Each product line seeking accreditation will be scored and reported separately.
  • Evaluation will be based on how many factors satisfy each applicable element and will be measured as:
    • Met, meeting all eligible points
    • Partially Met, meeting half of the eligible points
    • Not Met, meeting no eligible points.

In addition, status levels of accreditation, including excellent and commendable, will be eliminated. NCQA will instead use a separate health plan ratings system to differentiate quality between health plans. New, must-pass elements will also be incorporated into the credentialing and utilization management standards.

NCQA is also moving from a numeric 1-5 rating structure to a “star” rating system of 1–5 stars. Ratings will be released in September of each year, starting with September 2020, which will use the June 2020 HEDIS data.

In order to evaluate the current status compared to the projected future scores, NCQA provided the comparison below:

Current StatusProjected Status
Excellent4.5-5.0
Commendable3.5-4.0
Accredited2.5-3.0
Provisional1.0-2.0

[1] NCQA.org

If all of the changes have your plan scrambling, the Health Management Associates (HMA) team of NCQA experts can help. Our team has completed a deep assessment of the new scoring methods and is ready to guide your team through this critical transition. Our experts have an unmatched accreditation track record as former health plan executives and operations specialists and as current trusted health plan advisors.

Our accreditation experts understand the complexity organizations face when undergoing accreditation and the challenges in sustaining and incorporating quality in everyday processes. They have guided numerous plans to successful accreditation outcomes and been able to help plans escape the cycle of accreditation fire drills by tailoring our Survey Ready Model to their organization. Implementing a Survey Ready Model equips staff across a plan with the tools and processes needed to maintain business operations that ensure the plan is “survey ready” year around.

Our team is ready to help your team with the NCQA scoring transition, adopting a Survey Ready business approach, and any other challenges you may be facing. Connect with our NCQA Accreditation team here.

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