Reform Alert - News from the Blues' Office of National Health Reform

Exchange: accreditation of qualified health plans

Update: March 7, 2013 - HHS releases essential health benefits, actuarial value, and accreditation final rule

July 10, 2012

On June 1, 2012 the Department of Health and Human Services issued a proposed rule, establishing a two-phase approach to recognize accrediting entities for the purposes of accrediting qualified health plans.

What is accreditation? 

As a component of the QHP certification necessary in order for a QHP to operate on an Exchange, a health plan must be accredited. Accreditation is a process by which an impartial organization reviews a company's operations to ensure the company is conducting business in a manner consistent with standards set by the Affordable Care Act.

The preamble to the proposed rule states HHS considered recognition of both the National Committee for Quality Assurance and URAC* as accrediting entities. The recognition of NCQA and URAC as approved accrediting entities is effective until it is rescinded or the interim phase one process is replaced by future rulemaking.

In order to be recognized as an accrediting entity by HHS, an accrediting entity must provide HHS its current accreditation processes to demonstrate the process meets all requirements necessary to perform QHP accreditation. Initial submission of such documentation will be made at a time frame specified by HHS. An accrediting entity must submit any proposed changes or updates to its accreditation and measurement processes to HHS with 60 days notice prior to implementation.

At this time, Blue Cross Blue Shield of Michigan is pursuing NCQA accreditation. BCN has been NCQA accredited for several years.

What should we expect to see in phase two?

The proposed rule provides an initial indication of what to expect in future rulemaking regarding phase two of the recognition of accrediting entities, including:

  • Application procedure; 
  • Standards for recognition; 
  • A criteria-based review of applications; 
  • Public participation; and 
  • Public notice of recognition. 

Will there be separate accreditation determinations for each product?

Yes. The rule proposes that recognized accrediting entities provide separate accreditation determinations for each product type offered by a QHP issuer in each Exchange (i.e., Exchange HMO, Exchange POS, and Exchange PPO).

What are the Standards for Clinical Quality Measures?

Recognized accrediting entities must include a clinical quality measure set in their accreditation standards for health plans. The quality measure set must:

  • Span a breadth of conditions and domains, including, but not limited to, preventive care, mental health/substance abuse, chronic care, and acute care; 
  • Include measures applicable to adults and children; 
  • Align with the priorities of the National Strategy for Quality Improvement in Health Care issued by HHS in 2011; 
  • Only include measures that are either developed or adopted by a voluntary consensus standards setting body, or, where appropriate measures are unavailable, are in common use for health plan quality measurement and meet health plan industry standards; and 
  • Be evidence-based. 

Will data be shared between Accrediting Entities and Exchanges?

A QHP issuer is required to authorize the entity that accredits its QHPs to release to the Exchange and HHS certain materials related to QHP accreditation. Such information would be provided to the Exchange during the annual certification period or as changes occur throughout the coverage year.

Where can I find more information?

At this time, HHS is soliciting comments on the proposed rule and hopes to receive comments regarding:

  • Data requirements; 
  • Whether or not there are other accrediting entities that currently meet or would meet the statutory requirements this year; 
  • Comments on this level of accreditation, in addition to circumstances in which exceptions should be made to the accreditation determination being made at the product type level; and 
  • Comments to inform future rulemaking. 

Blue Cross Blue Shield of Michigan will continue to monitor regulations and updates will be provided as soon as they become available.

Click here for more information on the proposed rule (PDF).

* Formerly known as the Utilization Review Accreditation Commission until 1996.

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.