Question

Explain and summaries the difference between NCQA and the URAC organization and their responsibilities as they relates to managed care.

Answer 1

Ans) LEGISLATION & REGULATION

URAC and NCQA Work With Plans To Get Them Qualified for Exchanges:

The Affordable Care Act requires insurers to measure up if they want to participate in the new state marketplaces for individual policie

- Under the Affordable Care Act, health plans angling for a spot on state health exchanges are required to be accredited by one of the two big national organizations — URAC or the National Committee for Quality Assurance.

- And with regulators interested in having a variety of competitive plans in the subsidized marketplace — the Obama administration’s effort to greatly widen health care coverage in the U.S. — regulators have been careful to leave a clear path to accreditation for longtime players and newcomers alike.

Existing accreditation

Current plans on the market that are being adapted to fit the federal mold for benefits in the exchanges will be allowed to operate with their existing accreditation, if they have one, until it comes up for a renewal.

Plans just getting started, meanwhile, are finding plenty of eager helpers at both URAC and the NCQA to gain interim accreditation on their policies and procedures until audits can start in 2015 to see how they’ve been doing in actual practice.

The managed care industry can also look forward to a federal plan to standardize quality measures into one approach that will play a big role in determining how well they’re performing.

“We have had a large number of plans come to us to start the accreditation process,” says Vern Rowen, URAC’s senior vice president for external and legal affairs. “Some are ahead of the curve.” The mix includes existing plans and new organizations — including provider-sponsored groups — which are not all ready to go.

How well plans are fixed on accreditation has a lot to do with what state they operate in, says Ledia Tabor, the director of the “quality solutions” group at NCQA and the staff expert on health exchanges.

In some states —Maryland is one — that have laws requiring accreditation or some big employers demand it, obtaining and maintaining accreditation is standard operating procedure. Move to a state like Wyoming, though, where insurers have operated without that mandate, and you’ll find plans stepping up for the first time.

For many of these national players, particularly in the large managed care organizations, gaining accreditation is routine, Rowen notes. Some states require accreditation for Medicaid plans.

One brand new niche, though, is being created for the co-ops being encouraged in every state

These co-ops are typically dominated at the board level by consumers and are intended under the ACA to provide some diversity and competition among the plans competing on the state exchanges.

The big idea here is to spur the development of plans “that inspire choice,” avoiding a situation where a state exchange may just have one of the big Blues and/or some other national insurer’s plan, Tabor says.

Essential services

Many of these co-ops are working with national insurers to contract for essential services, like renting a network of providers so they can get started, says Tabor. Many are still fledgling operations, often still engaged in renting space, hiring staffers, and getting accredited for the first time.

One short step away

For these first-timers, says Tabor, talking to them about accreditation is one short step away from consulting. NCQA representatives will review with plan representatives all the structures and processes that are at the heart of accreditation. That can include a detailed look at how they plan to handle consumer complaints or credential providers.

Later, when they get some actual experience running the operation, the NCQA will go back and run an audit on performance, adding a review of HEDIS (the Healthcare Effectiveness Data and Information Set), widely used to measure performance on issues like breast cancer screening and blood pressure control and CAHPS (Consumer Assessment of Healthcare Providers and Systems) scores.

“We look at a plan’s structures and processes and policies, such as how they credential