Kaiser Family Foundation Survey on State Medicaid Managed Care ...

National Committee on Quality Assurance (NCQA) or URAC. NCQA accreditation is widely considered todemonstrate that a health plan has in place the structure and processes necessary for high-quality care,including systems to measure performance and identify areas for improvement, and the processesneeded to improve care. In addition, NCQA accreditation means that health plan performance data willbe reported nationally and that the health plan will be ranked annually as part of a national process17 18conducted in conjunction with Consumers Union.Sixteen of the 36 states with MCOs reported that they require Medicaid MCOs to be accredited. All ofthem recognized NCQA accreditation, and six also recognized URAC and three recognized AccreditationAssociation for Ambulatory Health Care (AAAHC) accreditation. Some states do not mandateaccreditation, but recognize or encourage it. For example, Pennsylvania does not require accreditation,but does require Medicaid plans to submit HEDIS© data to NCQA, and all health plans except two newones are NCQA-accredited, with Excellent ratings. It is less common for states to require accreditationfor non-comprehensive PHPs. Just four states (DC, Florida, Iowa, and North Carolina) reported that theyrequire these plans to be accredited to participate in Medicaid.Because NCQA requirements are at least as rigorous as federal standards, even states that do notrequire accreditation may deem NCQA-accredited plans to meet certain state and federal requirements.For example, California does not require accreditation but health plans with NCQA accreditation aredeemed to meet state provider credentialing requirements. Ohio and Oregon deem health plans thatare accredited to have met certain CMS requirements. Eight states deem federal external quality reviewrequirements to be met for accredited MCOs.Nearly all states collect, monitor, analyze, and report HEDIS©, CAHPS©, and similar state-specificperformance or quality measures in their managed care programs. States can choose from a largeinventory of performance measures developed by national bodies such as NCQA or the National QualityForum, or create measures of their own. For cost reasons, most states do not require health plans andproviders to report on all measures. Rather, they select or develop measures focused on priority issuesor concerns. Only three states with any form of managed care indicated that they did not useperformance measures to assess quality – Mississippi, which began contracting with MCOs in 2011, wasselecting measures in 2011, and North Dakota and South Dakota (which do not have MCOs) reportedthat they do not use performance measures in their PCCM programs.• MCO performance measurement. All states with MCOs (except Mississippi, with a newlyimplemented MCO program) indicated that, as of October 2010, they used performance measuresto assess access and the clinical quality of care in their health plans. Most states selected measuresfrom the HEDIS© data set developed by NCQA, often supplementing with measures developed bystate staff to assess specific issues.The median number of measures that states require Medicaid MCOs to report is 32, consistingprimarily of HEDIS© measures but also including state-specific measures. However, the numbervaried considerably by state. Of the measures used by NCQA for accreditation of Medicaid MCOs,17The 2010-2011 NCQA national rankings of Medicaid health plans can be found at:http://www.ncqa.org/portals/0/health%20plan%20rankings/2010/HPR2010_NCQA_Plan_Ranking_Summary_Medicaid.pdf.18The 2011-2012 NCQA rankings are published in September 2011 athttp://www.ncqa.org/tabid/1329/Default.aspx.34 00