all materials © 2012, national committee for quality assurance ncqa update - 2014 national...
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All materials © 2012, National Committee for Quality Assurance
NCQA Update - 2014
National Credentialing ForumFebruary 6, 2014
2NCQA UpdateFebruary 6, 2014
EXCHANGES
3NCQA UpdateFebruary 6, 2014
Federally-Facilitated Exchanges: Requirements Phase in
Certification Year QHP issuers without
existing accreditation
QHP Issuers with existing Commercial,
Medicaid accreditation for the
state
Year 1 (2013) Schedule accreditation review
Attest that accredited policies and procedures are comparable to Exchange (not all the same)
Years 2 and 3 (2014-2015)
Be accredited for Exchange product (policies and procedures)
Attest that accredited policies and procedures comparable to Exchange
Year 4 (2016) Exchange product is accredited, performance data submitted
4NCQA UpdateFebruary 6, 2014
HPA 2013 - 2014EVALUATION OPTIONS
5NCQA UpdateFebruary 6, 2014
What is an Evaluation Option?
• An Evaluation Option is defined by its distinct combination of:– Requirements (standards and measures)– Scoring– Statuses– Length of accreditation
6NCQA UpdateFebruary 6, 2014
Three Evaluation Options
Evaluation Option
Eligibility Duration Scope
InterimUnaccredited plans 18 months
Policy/Procedures (prior to survey look back period)No file review
First Unaccredited plans 36 months
Policy/Procedures and evidence of implementation (6 month look back)
RenewalPlans with NCQA Accreditation
36 months
Policy/Procedures and evidence of implementation (24 month look back)
7NCQA UpdateFebruary 6, 2014
How Measures and Scoring Fit In
Evaluation Option
Measure Requiremen
ts
Maximum Point
Allocation
Maximum Status
Interim Not Required Standards—50 points Interim
First Optional
Standards—50 points
Accredited
Standards—50 pointsHEDIS—37 pointsCAHPS—13 points
Excellent
Renewal Required
Standards—50 pointsHEDIS—37 pointsCAHPS—13 points
Excellent
8NCQA UpdateFebruary 6, 2014
So what’s happened
• NCQA has accredited XXX Exchanges
• Were accredited under the Interim standards or as an “Add-on” to currently accredited plans
• Those with Interim status will be coming through First Evaluation Option at the end of December 2014 and 2015.
9NCQA UpdateFebruary 6, 2014
CREDENTIALING UPDATE 2014
10NCQA UpdateFebruary 6, 2014
CR 3: Credentialing Verification• Added
– Factor 4: Verification of board certification status, if applicable.
• Documentation– No new requirements
• Rationale– Allows separate verification of boards that
cannot be used to meet E & T requirement.– Allows for verification of certification for
recertification.
11NCQA UpdateFebruary 6, 2014
Possible Change in 2016 • Adding the following for Exchanges
– Essential Community Providers (ECP) • Providers with experience caring for medically
underserved populations.• Include community health clinics, Ryan White
HIV/AIDS providers, Family Planning Providers (Title X Family Planning Clinics), Indian Providers and safety-net hospitals (hospitals that receive disproportionate Share Hospital funding), STD Clinics, TB Clinics, Hemophilia Treatment Centers, Black Lung Clinics.
• Go to https://data.cms.gov/dataset/Non-Exhaustive-List-of-Essential-Community-Provide/ibqy-mswq for a full list.
12NCQA UpdateFebruary 6, 2014
Possible Change in 2016 • Adding the following for Exchanges
– Children’s Dental Services• Currently only oral surgeons are included in NCQA
credentialing requirements.• May need to add dentists who treat children in future.
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