NCQA member engagement standards change accreditation paradigm for Medicaid plans

ACA mandates that plans offering insurance products on health benefit exchanges (HBE) maintain full accreditation with standards boards like NCQA or URAC. Generally considered the gold standard for accreditation, state Medicaid programs are increasingly adding NCQA compliance to their contracts with Medicaid MCOs.

Traditionally exempt from NCQA’s Member Connections standards (MEM), Medicaid MCOs must now meet MEM standards by the July 1, 2015, deadline if their state contract requires broad NCQA accreditation or they are offering plans on HBEs. Additionally, plans renewing accreditations after July 1, 2015, are still required to demonstrate to NCQA they have compliant programming in place to meet MEM standards by July 1, 2015.

Since HEDIS/CAHPS scores account for 50 percent of a plan’s overall NCQA accreditation scores and remain static for three years, Medicaid MCOs need strategies to help bolster other components of their overall score — including MEM. Although most plans already meet some MEM standard components through their use of health risk assessments and self-management tools, meeting other MEM standards may pose challenging.

MEM standards require Medicaid MCOs to offer web-based self-management tools and share full assessment results with enrollees, not just summary assessment scores. Medicaid MCOs must also be able to share claims/encounter information with enrollees who ask for this information, even if enrollees have no financial responsibility for the services they use.

Demonstrating engagement with Medicaid members

An important component of MEM is demonstrating that tools and educational content are tested for usability within Medicaid populations. This will require some thought about how best to engage specific Medicaid enrollee segments going forward — children and mothers, the aged, blind and disabled, and special needs populations will likely have different usability standards. Investing in engagement strategies will almost certainly pay off if enrollees are to become more proactive in managing their health.

Traits for MEM success

Achieving MEM requires three things: cross-plan planning efforts and investment; thorough reviews of state contract requirements to make sure literacy and language requirements inform compliance initiatives; and reviews of any vendor arrangements that impact accreditation. This third criteria is important as Medicaid MCOs must have frank discussions with quality improvement teams and/or vendor partners to ensure operational compliance with MEM standards.

To learn more about strategies for meeting MEM standards, please download our article, “NCQA member engagement standards change accreditation paradigm for Medicaid plans.”

–Natalie Ellertson, Vice President, Clinical Improvement Solutions, Optum

About the author:

Natalie_Ellerston_resizeEllertson’s has worked with government funded programs at the state, local and federal levels for almost 25 years. She conducted policy research and development for a Washington, DC based think tank and worked as a policy aide for elected officials in both the U.S. and the UK.  She has 15 years of strategic planning and performance management consulting experience.

Past clients include the Centers for Medicare and Medicaid Services (CMS), several state and local departments of health and human services, and military health care entities.  She currently builds  clinical improvement programs for Medicaid recipients serviced in both MCOs and ACOs.

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