Accreditation is a rigorous and comprehensive evaluation process through which NCQA assesses the quality of the key systems and processes that define health care organizations. Employers, consumers, regulators and health plans turn to NCQA Accreditation as the gold standard in evaluating health care quality. For many plans, Accreditation is voluntary. For others, state regulation requires NCQA Accreditation in whole or in part. View more information about Accreditation.
The type of health plan offered by different health care organizations. NCQA uses the same standards and process to evaluate all types of plans (HMO, MCO, POS, PPO).
The Health Plan Report Card previously listed three types of NCQA Accreditation: Health Plan Accreditation, MCO Accreditation and PPO Accreditation. NCQA has discontinued its distinct MCO and PPO Accreditation Programs in favor of a single, consolidated accreditation program that uses a common set of standards and guidelines. The Health Plan Accreditation Program applies to HMO, MCO, POS and PPO plans.
A set of standardized surveys that measure patient satisfaction with the experience of care. CAHPS® is sponsored by the Agency for Health Care Research and Quality (AHRQ).
HEDIS (Healthcare Effectiveness Data and Information Set) is a registered trademark of the National Committee for Quality Assurance. It is a tool used by more than 90 percent of America's health plans to measure performance on important areas of care and service. Altogether, HEDIS consists of 76 measures across 5 domains of care. HEDIS measures address areas of care such as asthma medication use and controlling high blood pressure. View more information about HEDIS.
Managed care is a type of health care coverage that manages costs through its own network of physicians and pre-authorizes appointments with physician specialists.
A quantifiable measure to assess how well the organization carries out specific functions or processes.
Overall Accreditation Status
Overall Accreditation Status refers to the level of NCQA Accreditation a plan has received. NCQA Accreditation is a thorough and rigorous evaluation of a health plan for quality measurement and continuous quality improvement by NCQA.
NCQA awards its highest accreditation status of Excellent to organizations with programs for service and clinical quality that meet or exceed rigorous requirements for consumer protection and quality improvement. HEDIS results are in the highest range of national performance.
NCQA awards a status of Commendable to organizations with well-established programs for service and clinical quality that meet rigorous requirements for consumer protection and quality improvement.
NCQA awards an accreditation status of Accredited to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take further action to achieve a higher accreditation status.
NCQA awards a status of Provisional to organizations with programs for service and clinical quality that meet basic requirements for consumer protection and quality improvement. Organizations awarded this status must take significant action to achieve a higher accreditation status.
NCQA denies Accreditation to organizations whose programs for service and clinical quality did not meet NCQA requirements during the Accreditation survey.
Appealed by Plan
NCQA designates Appealed by Plan to an organization when an accreditation status is under review at the request of that health plan.
NCQA designates In Process to an organization when NCQA has surveyed the organization and is in the process of making a decision on accreditation status.
NCQA revokes Accreditation to an organization when circumstances have caused NCQA to withdraw Accreditation.
NCQA designates Scheduled when a health plan is on NCQA's schedule for an Accreditation Survey.
NCQA suspends an organization when circumstances have caused NCQA to suspend Accreditation until it completes a thorough investigation and the health plan takes corrective action if needed.
Expired indicates a plan that was previously accredited has chosen not to undergo a survey to renew its status.
Under Review by NCQA
NCQA designates Under Review to an organization after NCQA has chosen to review the organization to assess the appropriateness of an existing accreditation status.
Merger Review in Process
NCQA designates Merger Review in Process to an organization that has informed NCQA that it is merging with another organization. NCQA will subsequently conduct a review of the merger to determine its impact on the organization's accreditation and certification status.
Plan name is the name of the organization that provides health care coverage to individuals and families.
The Plan Type refers to a specific plan that is designed to provide health care coverage to a certain population or group of people. NCQA divides plan type by Commercial, Medicare, Medicaid and Health Insurance Marketplace or Exchange
Commercial is a type of health care coverage paid for by employers or individual consumers.
Medicare is the federal government’s health care program for all persons over the age of 65 and for younger persons who have disabilities and cannot work.
Medicaid is a federally-mandated and state-funded health care program for low income or disabled persons.
Health Insurance Marketplace or Exchange
Health Insurance Marketplaces provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance policies eligible for federal subsidies.
A copayment is a fixed dollar amount that the patient must pay out-of-pocket for a particular health care service at the time of visit.
The amount of money the insured patient must pay out-of-pocket before the insurance company must begin paying benefits. For example, if there is a $500 deductible, the insured patient must pay for the first $500 of health care expenses before the insurance company will begin paying claims.
The annual out-of-pocket maximum is the maximum amount a health plan will require the policy holder to contribute out-of-pocket towards the cost of care. This protects the insured from very high costs by capping the total amount spent on your health care each year. The policy holder must meet the annual deductible first before the annual out-of-pocket maximum applies. Once the deductible is met, copays will count towards the annual out-of-pocket maximum. Once the annual out-of-pocket maximum is reached, the policy holder should no longer be required to contribute towards the cost of care. In most cases, insurance covers 100 percent of the services required.
A premium is a periodic payment, often in installments, made on an insurance policy.
Star ratings provide a view of plan performance in five categories. To calculate the star ratings, accreditation standards scores and HEDIS measure scores are allocated by category. The plan’s actual scores are divided by the total possible score. The resulting percentage determines the number of stars rewarded.
Access and Service
NCQA evaluates how well the health plan provides its members with access to needed care and with good customer service. For example: Are there enough primary care doctors and specialists to serve the number of people in the plan? Do patients report problems getting needed care? How well does the health plan follow up on grievances? To evaluate these activities, NCQA reviews appeals and health plan denials records, interviews health plan staff and grades the results from consumer surveys. Plans with Health Plan Accreditation may receive up to 4 stars.
NCQA evaluates health plan activities that ensure each doctor is licensed and trained to practice medicine and that the health plan's members are happy with their doctors. For example: Does the health plan check whether physicians have had sanctions or lawsuits against them? How do health plan members rate their personal doctors or nurses? To evaluate these activities, NCQA uses records of doctors' credentials, interviews health plan staff, and grades the results from consumer surveys. Plans with Health Plan Accreditation may receive up to 4 stars.
NCQA evaluates health plan activities that help people maintain good health and avoid illness. For example: Does the health plan give its doctors guidelines about how to provide appropriate preventive health services? Are members receiving tests and screenings as appropriate? To evaluate these activities, NCQA reviews health plan records, grades independently verified clinical data and reviews materials sent to members. Plans with Health Plan Accreditation may receive up to 4 stars.
NCQA evaluates health plan activities that help people recover from illness. For example: How does the health plan evaluate new medical procedures, drugs and devices to ensure that patients have access to the most up-to-date care? Do doctors in the health plan advise smokers to quit? To evaluate these activities, NCQA reviews health plan records and interviews health plan staff. Plans with Health Plan Accreditation may receive up to 4 stars.
Living with Illness
NCQA evaluates health plan activities that help people manage chronic illness. For example: Does the plan have programs in place to assist patients in managing chronic conditions like asthma? Do diabetics, who are at risk for blindness, receive eye exams as needed? NCQA grades independently verified clinical data and interviews health plan staff. Plans with Health Plan Accreditation may receive up to 4 stars.
A standard is a basis for comparison or a reference point against which organizations can be evaluated. NCQA standards are statements about acceptable performance.