Plan Accreditation

A health plan's accreditation status provides an impartial opinion about its quality. An impartial organization accredits a health plan when it determines that the health plan's practices meet national standards.

The following independent, private, not-for-profit organizations dedicated to measuring the quality of health care organizations accredit health plans in the FEHB Program. A health plan's brochure cover will show its accreditation status and the accrediting organization.

Examples of Accrediting Organizations:

Accreditation Association for Ambulatory Health Care (AAAHC)

The Accreditation Association for Ambulatory Health Care (AAAHC) is a private, not-for-profit organization with the mission of improving health care quality through accreditation. AAAHC Accreditation programs are based on nationally recognized Standards and a unique peer-based review system. AAAHC Accreditation assesses the health plan's effectiveness of administering the delivery of appropriate, accessible, high-quality health care and services to defined memberships.

The on-site survey process is founded on a collaborative, consultative, educational approach to on-site review of each organization seeking Accreditation.

Accredited: AAAHC concludes that an organization is in substantial compliance with the Standards on Member Rights, Responsibilities, and Protections; Governance; Administration; Delegation; Provider Network Credentialing; Network Adequacy; Case Management and Care Coordination; Health Education and Wellness Promotion; and Quality Improvement and Management, complies with AAAHC accreditation Policies and Procedures, and there are no reservations about the organization's continuing commitment to provide high-quality services consistent with the Standards.
Denied: AAAHC concludes that the organization is not in substantial compliance with AAAHC Standards and/or Policies and Procedures. Additionally, a compliance rating if less than fully compliant for a Standard identified as must fully meet could serve as sufficient grounds for denial of accreditation.

National Committee for Quality Assurance (NCQA)

The National Committee for Quality Assurance (NCQA) is a private, nonprofit organization dedicated to improving health care quality. NCQA Accredits and Certifies a wide range of health care organizations and recognizes clinicians in key clinical areas. NCQA's HEDIS® is the most widely used performance measurement tool in health care. NCQA's website (www.ncqa.org) contains information to help consumers, employers and others make informed health care choices.

NCQA Health Plan Accreditation builds on more than 30 years of experience to provide a current, rigorous and comprehensive framework for essential quality improvement and measurement. It is the only program in the industry that bases results on clinical performance and consumer experience (HEDIS® and CAHPS®). The use of HEDIS data allows NCQA Health Plan Accreditation to effectively measure care and service performance. This focuses attention on activities that keep members healthy. NCQA standards are a roadmap for improvement—organizations use them to perform gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. Standards evaluate organizations on:

Quality Management and Improvement.
Population Health Management.
Network Management.
Utilization Management.
Credentialing and Recredentialing.
Members’ Rights and Responsibilities.
Member Connections.
Medicaid Benefits and Services.
Quality Management and Improvement.
Population Health Management.
Network Management.
Utilization Management.
Credentialing and Recredentialing.
Members’ Rights and Responsibilities.
Member Connections.
Medicaid Benefits and Services.

Utilization Review Accreditation Commission (URAC)

URAC, is an independent, not-for-profit organization leading the way to exceptional health care for all. Members of a multidisciplinary advisory group shared their industry knowledge and experiences in the development and revision of standards. The group included payers, doctors, hospitals, URAC’s Board of Directors, Standards Committees and other industry experts.

URAC offers multiple accreditation options to meet the various needs of health plans; Health Plan, Health Plan with Long-Term Services and Supports, Medicaid Health Plan, Medicaid-Health Plan with Long-Term Services and Supports, and Marketplace Health Plan. Once achieved, URAC's accreditation signals to consumers, purchasers, regulators, and others an organization's commitment to quality and accountability.