2012 Public Comment Overview
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2012 Public Comment Overview

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For Public Comment March 4–April 1, 2011 Comments due 5:00 pm ET Friday, April 1, 2011 2012 Accreditation and Certification Products Update Overview ®HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). ®CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Note: This publication is protected by U.S. and international copyright laws. You may reproduce this document for the sole purpose of facilitating public comment. 2011 by the National Committee for Quality Assurance 1100 13th Street NW Suite 1000 Washington, DC 20005 All rights reserved. Printed in U.S.A. NCQA Customer Support: 888-275-7585 www.ncqa.org Overview of Draft Changes to 2012 Products 1 Overview Our Mission: Improve the Quality of Health Care NCQA is dedicated to improving health care quality. For more than 20 years, NCQA has been driving improvement throughout the health care system, helping to advance the issue of health care quality to the top of the national agenda. NCQA’s programs and services reflect a straightforward formula for improvement: measurement, transparency and accountability. This approach works, as evidenced by dramatic improvements in clinical quality demonstrated by health plans that NCQA accredits—health maintenance organizations (HMO), ...

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2012 Accreditation and
Certification Products
Update
Overview
For Public Comment
March 4–April 1, 2011
Comments due 5:00 pm ET
Friday, April 1, 2011
HEDIS
®
is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS
®
is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Note:
This publication is protected by U.S. and international copyright laws. You may reproduce this document for the
sole purpose of facilitating public comment.
2011 by the National Committee for Quality Assurance
1100 13th Street NW Suite 1000
Washington, DC 20005
All rights reserved. Printed in U.S.A.
NCQA Customer Support: 888-275-7585
www.ncqa.org
Overview of Draft Changes to 2012 Products
1
Overview of Draft Changes to 2012 Products
2012 Product Update—Draft Changes for Public Comment
Obsolete after 4/1/11
Overview
Our Mission: Improve the Quality of Health Care
NCQA is dedicated to improving health care quality.
For more than 20 years, NCQA has been driving improvement throughout the health care system, helping to
advance the issue of health care quality to the top of the national agenda. NCQA’s programs and services
reflect a straightforward formula for improvement: measurement, transparency and accountability.
This approach works, as evidenced by dramatic improvements in clinical quality demonstrated by health plans
that NCQA accredits—health maintenance organizations (HMO), point-of-service (POS) and preferred
provider organizations (PPO)—using both standards and performance results. Today, two in five Americans
are enrolled in a plan that collects and reports HEDIS data to NCQA.
Health Plan Accreditation
NCQA Health Plan Accreditation is designed to help employers, public purchasers and consumers
understand and distinguish among health plans based on quality, while helping health plans identify
opportunities for quality improvement.
To remain current with the health care industry’s changing capabilities and priorities, NCQA regularly updates
its accreditation and certification requirements. Proposed updates for 2012 highlight opportunities to
incorporate industry changes, such as the new Patient Protection and Affordable Care Act (PPACA)
requirements for all health plans.
In addition to annual updates and PPACA requirements, NCQA is interested in receiving comments about:
Delivery system reform
Health insurance Exchanges.
Patient Protection and Affordable Care Act Requirements
NCQA reviewed all Affordable Care Act requirements that became effective in 2010, which are applicable for
all health plans. When assessing requirements to include in the standards, NCQA considered whether an
addition would enhance the quality and strength of the standards and the evaluation process. NCQA
determined that many requirements are already addressed in the current accreditation standards and some
are more appropriate for federal review than for an accreditation-based review. NCQA’s Standards
Committee recommended including provisions related to the appeals process (29 CFR Part 2590; Section
54.9815—2719T), which incorporate the following requirements:
Clarify the definition of ―adverse benefit determination‖ to include rescissions of coverage
Expedite notification of benefit determinations involving urgent care
Include full and fair review of evidence used to determine a denial
Avoid conflict of interest by not influencing decisions through hiring, compensation, termination,
promotion or other practices
Provide notice to claimants with sufficient information about an adverse benefit determination or a final
internal adverse benefit determination.
2
Overview of Draft Changes to 2012 Products
Overview of Draft Changes to 2012 Products
2012 Product Update—Draft Changes for Public Comment
Obsolete after 4/1/11
NCQA proposes aligning with federal requirements by adding rules related to the appeals process. We
welcome feedback on our general approach for incorporating these requirements, as well as
recommendations for additional components our stakeholders believe should be included.
Delivery System and Payment Reform
Delivery system and payment reform initiatives such as patient-centered medical homes (PCMH) and
accountable care organizations (ACO) are receiving significant attention as methods of simultaneously
reducing cost and improving quality. NCQA is considering opportunities to encourage health plan investment
in these types of system redesign initiatives through health plan accreditation. We want your input on
strategies to reward health plans for supporting initiatives such as PCMH, for use in the NCQA Accreditation
standards.
We are considering offering delegation oversight relief when delegating certain case management or disease
management activities to NCQA Recognized PCMH practices.
Questions for consideration:
Should NCQA allow plans to delegate to practices for case management or disease management? If
so, which activities?
How else could NCQA reward health plans for investing in delivery system and payment reform
initiatives?
How do health plans currently support delivery system and payment reform?
Health Insurance Exchanges
The Patient Protection and Affordable Care Act (PPACA) creates health insurance Exchanges, a new avenue
for the currently uninsured to purchase health insurance coverage in an organized and competitive market.
Exchanges will be created and operated in each state and will offer a choice of health plans, with common
rules about offering and pricing insurance. Exchanges will also provide information on health plans and
benefit plans, to help consumers understand their options. Operation of Exchanges will be directed by federal
government requirements and by requirements established by the state Exchange governance.
State Exchanges will be responsible for certifying health plans that are qualified to provide products in the
Exchange market. A PPACA requirement for qualified health plan is that at a minimum, a plan
“must be
accredited with respect to
local performance on clinical quality measures such as the Health Effectiveness Data and Information
Set,
patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and
Systems survey, as well as
consumer access,
utilization management,
quality assurance,
provider credentialing,
complaints and appeals,
network adequacy and access, and
patient information program” (Section 1311).”
Overview of Draft Changes to 2012 Products
3
Overview of Draft Changes to 2012 Products
2012 Product Update—Draft Changes for Public Comment
Obsolete after 4/1/11
Broad federal accreditation requirements align closely with the current NCQA Health Plan Accreditation
program. Plan-level HEDIS and CAHPS measure results reported to NCQA for accreditation can also be used
to aid additional qualified health plan certification requirements, Exchange oversight and consumer
information reporting.
NCQA is interested in receiving feedback about issues we should consider to align accreditation and HEDIS
and CAHPS reporting with federal and developing state Exchange requirements. NCQA will use Public
Comment feedback and will continue to work with health plans and federal and state governments to help
these parties meet and oversee Exchange requirements. NCQA will release additional information and
questions in the near future.
Public Comment
Public Comment is integral to the development of all NCQA standards and measures. NCQA actively seeks
input from all interested parties during the development cycle of programs and routinely integrates input into
the final versions of its programs.
Comments on the proposed changes to NCQA Accreditation and Certification requirements will be considered
as NCQA finalizes the products for release in July 2011. Surveys incorporating these product changes will
begin on July 1, 2012.
Draft Changes
Changes
proposed
for…
Health Plan Accreditation (HP)
New Health Plan Accreditation (NHP)
Managed Behavioral Health Organization Accreditation (MBHO)
Disease Management Accreditation and Certification (DM)
Wellness & Health Promotion Accreditation (WHP)
Health Information Products Certification (HIP)
Standards
Incorporate updates from PPACA to HP accreditation.
NCQA proposes updating
the Utilization Management (UM) standards to align with the federal requirements in
the ACA.
Incorporate changes specific to MBHOs, NHPs, HPs.
Changes will align products
and simplify scoring.
HEDIS and
CAHPS
Add a HEDIS measure required for accreditation.
Add
Pharmacotherapy
Management of COPD Exacerbation (PCE)
to accreditation scoring.
4
Overview of Draft Changes to 2012 Products
Overview of Draft Changes to 2012 Products
2012 Product Update—Draft Changes for Public Comment
Obsolete after 4/1/11
Documents
Draft changes to 2012 Accreditation and Certification products are explained in detail in the following
documents.
Appendix 1: Updates to HP, NHP, MBHO, DM and WHP standards
Appendix 2: Affordable Care Act Updates to Health Plan Accreditation
Proposed changes to standards and to HEDIS/CAHPS scoring policies are shared to generate thoughtful
commentary and constructive criticism from interested parties. NCQA seriously considers all suggestions.
Many comments lead to changes in our standards and policies, and the review process makes our standards
stronger and more worthwhile for all stakeholders.
NCQA encourages readers to provide thoughts and insights on certain global issues related to the 2012
products update.
Are standards, intent statements and explanations clearly articulated? If not, which areas should be
more clear or need more explanation/examples?
Do standards align with organization services and stakeholder expectations? Are there gaps? Are there
areas that should be addressed but are not?
Generally, does your organization have the necessary materials (e.g., documents) to demonstrate
compliance with standards? If not, which areas are challenging?
Next Steps
Final 2012 NCQA Accreditation and Certification products will be released in July 2011, following approval by
the NCQA Standards Committee and the Board of Directors. Requirements will take effect July 1, 2012.
Plans coming forward for accreditation on or after that date must meet the new requirements.