NCQA Proposed Changes to Health Plan Accreditation Standards

May 14, 2018

Yellow Sign Proposed NCQA Changes Ahead

NCQA Proposed Changes to 2019 Health Plan Accreditation Standards

In keeping with the national focus and ongoing evolution of the healthcare environment, NCQA has been soliciting feedback and suggestions on some significant changes to existing Health Plan Accreditation (HPA) standards and HEDIS measures. NCQA is also exploring the possible need for updates to the CAHPS® 5.0H Survey.

SPH Analytics (SPH) has been monitoring NCQA communications and updates surrounding this initiative and has compiled the following overview to summarize these proposed changes.

Purpose and Goals

NCQA’s goal in proposing these changes is to ensure the focus and reporting requirements of Health Plan Accreditation standards:

  • Align with changes observed in the market
  • Align with other regulatory requirements (i.e., CMS)
  • Support the collective pursuit of ensuring efficiency, effectiveness, and quality in the delivery of care

Anticipated Updates to Health Plan Accreditation Standards

In March 2018, NCQA released an overview of the proposed 2019 Health Plan Accreditation Updates for public comment and feedback. These updates included multiple changes to existing requirements and the deletion of one or more elements in the existing standards. 

Proposed HPA Standard Updates

NCQA is proposing updates to elements of the following standards:

Utilization Management

UM 5, Elements A–D, H: Timeliness of UM Decisions

UM 5, Element H: Timeliness of UM Decisions

Member Connections

MEM 3, Element B: Personalized Information on Health Plan Services


Delegation Standards, Element B: Provision of Member Data to the Delegate

Proposed HPA Standard Deletions

NCQA is proposing deletion of requirements in the following standards:

Quality Improvement,

QI 1, Element A (Factor 3 and 9): Program Structure

QI 3, Elements A, C (Factor 2): Health Services Contracting

Utilization Management

UM 12, Element A: Triage and Referral for Behavioral Healthcare

UM Standards: Must-Pass Elements Scoring (Increase threshold on must pass elements from 50% to 80%)


CR 1, Element A (Factor 6): Credentialing Policies

CR 6, Element A (Factor 2 and 3): Notification to Authorities and Practitioner Appeal Rights


Delegation, Element C: Provisions for PHI

NCQA also shared a redacted draft of the existing standards outlining proposed changes and/or deletions. These changes were said to be based on comments and feedback from health plans, NCQA surveyors, and other stakeholders (including healthcare consumers, states, and CMS).

NCQA plans to release the final Standards and Guidelines for HPA 2019 in July 2018, following approval by the NCQA Standards Committee and the Board of Directors.

Pending Changes to CAHPS 5.0H

Of equal interest to health plans and SPH Analytics, are the anticipated changes to the CAHPS 5.0H Survey. NCQA, working in conjunction with the AHRQ CAHPS Consortium, is considering the need for updates to the CAHPS 5.0H Survey.  NCQA had requested feedback and suggestions from market stakeholders during the HEDIS public comment period from February 13 through March 13, 2018.

While NCQA is open to all feedback and suggestions, some of the topics or issues identified for consideration include:

  • Overall usefulness of the current CAHPS measures to health plans
  • Recommendations to shorten or update the CAHPS Survey to reflect additional topics of current interest to stakeholders and patients
    • For example, member experience with telehealth services or with a patient portal to communicate with a provider or obtain test results online and the member’s preference for accessing services beyond primary and specialty care
  • Level of interest in expanding or allowing for an alternative sampling methodology, such as the ability to differentiate/segment plan members into subpopulations
    • For example, patients with few visits versus those with chronic conditions (and potentially more visits)
  • Benefits of conducting the HEDIS CAHPS measurement and reporting on an ongoing basis versus annually (the current methodology)

SPH Applauds NCQA’s Initiative and Provides Feedback

SPH applauds NCQA’s continuing efforts to evaluate and improve the CAHPS 5.0H Survey. As an NCQA-certified survey vendor for the CAHPS 5.0H Survey since the program’s inception, SPH welcomed the opportunity to respond to the proposed changes based on our extensive experience administering CAHPS Surveys and understanding of our clients’ challenges and objectives.

Health plans are faced with multiple CAHPS Survey reporting and data submission requirements for NCQA and for state and federal reporting programs. SPH endorsed the suggestions to align the list of CAHPS measures (i.e., Coordination of Care, Shared Decision Making, Claims) required of regulatory quality programs (NCQA Accreditation, QHP QRS, CMS Star Ratings) for different lines of business (Commercial, Medicaid, Medicare).

The current CAHPS Survey methodology is based on a random sample of health plan members. SPH has advocated for a sampling alternative to allow plans to target high volume utilizers of care or services to satisfy minimum valid n requirement on gated questions for select CAHPS measures (i.e., Customer Service, Claims, Getting Care Quickly).

SPH also emphasized the potential benefits of more frequent data collection to assist health plans in monitoring change and developing targeted quality improvement initiatives with higher confidence.

Additional Pending HEDIS Changes

Proposed Behavioral Health Updates

Consistent with healthcare issues of national concern, NCQA has expanded their focus on behavioral health quality measures, opioid abuse, and the care needs of high-risk patients with multiple chronic conditions.

Following is a list of proposed new measure and those with proposed changes:

  • Proposed New HEDIS Measures: Risk Assessment of Opioid Use, Hospitalizations Following Discharge, Health Assessment for Individuals with Multiple High-Risk Chronic Illnesses, Adult Immunization Status, Prenatal Immunization Status, and four Long Term Services and Support Measures
  • Proposed Changes to Existing HEDIS Measures: Controlling High Blood Pressure, Follow-Up After Emergency Department Visit for Mental Illness, Plan All-Cause Readmissions

Measure Exclusion for Patients with Advanced Illness 

NCQA proposes to exclude members with advanced illness from 11 HEDIS measures that address prevention, screening, and disease management. NCQA explains that these measures are “designed and intended for the general adult population and may not be clinically appropriate, relevant or in line with goals of care for patients with advanced illness and frailty.”

Telehealth Care and Services

Telehealth is predicted to change the way healthcare is provided from the point of emergency care needed, monitoring patients with chronic conditions, and overall expanding patients’ access to care. Though the in-person interaction is often preferred in providing clinical care or services, research has shown telehealth services may be equally appropriate and effective.

NCQA introduced telehealth in seven behavioral health measures for HEDIS 2018. NCQA is, therefore, looking closely at select “HEDIS physical health measures” and the option to include telehealth services.

Looking Ahead

Prior to determining final updates to 2019 HEDIS/CAHPS measures, NCQA will review and discuss public comments with industry stakeholder groups, advisory committees, and user groups, including the CAHPS Consortium.

Continue to monitor the SPH Analytics website and subscribe to our blog for further updates and information about relevant healthcare industry related topics, regulatory developments, and SPH resources and solutions.

Additional Resources:


CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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