Health Plan Accreditation Requirements

FOCUS AREAS TO ENSURE HIGH QUALITY

NCQA Health Plan Accreditation requirements guide organizations to deliver high quality care that aligns with areas most important to states, employers and consumers.

Requirements cover these key areas:

• Quality improvement.
• Population health management.
• Network management.
• Utilization management.
• Credentialing and recredentialing.
• Members’ rights and responsibilities.
• Member connections.
• Medicaid benefits and services.

To see all program requirements, get the Standards & Guidelines document.

REQUIRED ORGANIZATION SERVICES

The standards are designed for organizations providing managed health care services but are not specific regarding the type of managed care services.

IS MY ORGANIZATION ELIGIBLE?

Any organization that provides managed health care services may apply for the NCQA Health Plan Accreditation if it meets the following criteria:

• Operates under an insurance license (e.g., HMO, POS, PPO, EPO), and
• Issues a contract for insurance for a defined population or contracts with an employer to provide managed care services for a self-insured population, and
• Provides services through an organized delivery system that includes ambulatory and inpatient health care sites, and
• Performs functions addressed in the standards (quality improvement, care coordination, utilization management, credentialing, member rights and responsibilities), either directly or through a service agreement, and
• Has a process for monitoring, evaluating and improving the quality and safety of care provided to its members, and
• Reports audited HEDIS results for designated HEDIS measures and CAHPS ratings and composites, as required for the selected Evaluation Option.

RELATED PROGRAMS

NCQA offers several related programs for organizations eligible for the Health Plan Accreditation. Each program helps organizations improve their operations and initiatives in targeted areas and demonstrate their commitment to quality.

Long-Term Services and Supports Distinction

NCQA offers a Long-Term Services and Supports (LTSS) Distinction for organizations who provide managed health services and coordinate social services for LTSS.

The standards provide a framework for organizations to deliver effective person-centered care that meets people’s needs and aligns with state requirements.

Learn more about NCQA LTSS Distinction for Health Plans.

Health Equity Accreditation Programs

Health Equity Accreditation Programs focus on the foundation of health equity work: building an internal culture that supports the organization’s external health equity work; collecting data that help the organization create and offer language services and provider networks mindful of individuals’ cultural and linguistic needs; identifying opportunities to reduce health inequities and improve care.

Learn more about Health Equity Accreditation for Health Plans.