NCQA Updates Health Plan Accreditation for 2020

Improvements to evaluating health plans and increasing transparency. Focus on implementing standards and achieving outcomes. Reducing the administrative burdens for health plans.

These are all prominent goals for NCQAs Health Plan Accreditation (HPA) 2020.

A common way to reduce burden on health plans, NCQA routinely retires certain requirements that have become standard practice or are no longer aligned with market needs. For 2020, NCQA will retire 22 previous requirements and will reduce conditions for which plans need to submit evidence at the time of renewal.

What’s updating?

Some of the updates by NCQA include aligning Health Plan Accreditation and Health Plan Ratings, simplified scoring, and ratings by product line, adding Must Pass Elements to Credentialing and Utilization Management to ensure accuracy and timeliness, reduce paperwork, and improve the health plan’s experience.

NCQA is focusing on these areas in HPA 2020:

  • Align Health Plan Accreditation and Health Plan Ratings. NCQA improved the methodology it used to evaluate and communicate health plan performance on clinical (HEDIS®) and patient experience (CAHPS®) measures, making it easier for health plans to understand how well it was performing.
  • Simplify scoring and improve transparency. NCQA transitioned scoring from a complex points system that used whole numbers, half numbers and percentages to a simpler scoring threshold.
  • Strengthen consumer protections. NCQA strengthened oversight in Utilization Management (UM) and Credentialing (CR) standards by adding new requirements and elements as “must-pass.”
  • Reduce the paperwork burden on health plans. As is often the case, NCQA retired some elements (22 in 2020) and reduced the number of elements for which plans must show evidence during renewal. NCQA has continued its focus on policy implementation and consumer protections.
  • Survey tool and process improvements.NCQA is enhancing the survey tool and simplifying the Accreditation process to improve the customer experience.


For 2019 and earlier Accreditation, health plans earned 50 points for either Standards and Guidelines or HEDIS® and CAHPS® for a total of 100 points.

Beginning in 2020, health plans must earn 80% in each accredited Standards and Guidelines category, and 0-5 stars for HEDIS® and CAHPS®.

Today, elements in health plan scoring are worth a certain number of points, which vary and were non-whole numbers. In 2020, health plans will receive elements worth either 1 or 2 points.

Having met all the standard elements, the health plan will now earn applicable points. If only partial elements are met, then the health plan earns half of the applicable points. And, if none of the elements are met, then the health plan earns no points. Pretty straight forward.

Which score matters?

Previously, the scoring methodology for the NCQA Health Plan Ratings and Accreditation status were different, meaning scoring was confusing. Employers, states, and consumer advocates wanted a single source authority on how health plans are performing.

Therefore, beginning with HPA 2020 and the 2020 HEDIS reporting year, Health Plan Ratings and Accreditation will align. This will improve consistency between Health Plan Ratings and Accreditation and create a simpler and transparent scoring methodology for plans. No more confusion.

Receiving Accreditation

Starting in 2020 a health plan will need to meet the following:

  • To earn Accreditation, health plans must:
    • Meet at least 80% of applicable points in each standards category.
    • Submit HEDIS/CAHPS reporting during the reporting period after their first full year of Accreditation.
      • Submit HEDIS/CAHPS annually thereafter.

In 2020, health plans will be evaluated on each element and will earn either “Met,” “Partially Met,” or “Not Met.” To make it easier, elements are now worth 1 or 2 points.

  • Met = Earns all applicable Accreditation points.
  • Partially Met = Earns half of applicable points.
  • Not Met = Earns no points.

If the plan earns:

  • 80%+ of applicable points, the plan earns accreditation.
  • Less than 80% or greater than or equal to 55% of applicable points, then the health plan earns accreditation and a Provisional status.
  • Less than 55% of applicable points, the health plan can be denied accreditation. However, with the new scoring system, the health plan will have a much better idea why they did not receive Accreditation and can work on those improvements.

Once accredited, plans will begin reporting HEDIS/CAHPS on an annual basis starting the year after they earn Accreditation.

Product line scores

This change affects organizations seeking Accreditation for multiple product lines. Previously, there were several elements for which health plans would submit evidence to NCQA by product line, but the plan would be awarded a cumulative score across product lines instead of a score for each, individual product line.

Starting with the HPA 2020 standards, NCQA will review and score elements by product line. NCQA will report scores for Standards by product line instead of averaging across multiple product lines.

What does this mean for a health plan? Areas that still need improvement are highlighted.

  • Health plans must show evidence or samples by product line for the selected elements. These elements will have a product-line specific scores instead of an average score.
  • Element scores are added for a standards category to generate a score that is specific to each product line.
  • Corrective action plans will address product lines with less than satisfactory scores.

Until an organization receives a Star rating, organizations that achieve Accreditation will display the seal with the type of Accreditation they received (Accredited, Provisional, or Interim). Health plans that are already Accredited and submit for HEDIS will continue submitting HEDIS/CAHPS annually. Plans that earn first-time or interim Accreditation are required to submit HEDIS/CAHPS during the first reporting period after their first full year of Accreditation.

IQVIA’s Healthcare Technology Accreditation Specialists will conduct an onsite assessment and analyze your current population health models and programs. They will identify potential process and data gaps, which may pose a challenge in complying with the new NCQA HPA Standards. After identifying any gaps, our Accreditation Specialists can assist your team with providing a road map to assist with the transition to the new HPA standards. They will assist with providing clinical business and technical support to accommodate the HPA accreditation requirements. The Accreditation Specialist can also assist with re-designing your current program and if necessary, developing new, cost-effective managed care solutions designed for your members’ unique needs, while also meeting the NCQA HPA Standards.

To learn more about the IQVIA’s Healthcare Technology Population Health practice and what we can do to help organization with NCQA Accreditation needs, please reach out to Chris McShanag, vice president, population health.