Health Plan Accreditation

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Under the ACA, to operate on the Exchanges, qualified health plans must be accredited by a recognized accrediting entity such as URAC.

URAC’s Health Plan Accreditation is a nationally recognized symbol of excellence, respected throughout the healthcare industry and by the federal and state governments as an assurance that the organization meets rigorous standards and measures of quality and operational integrity, with a strong focus on consumer protection and empowerment. Achievement of URAC accreditation demonstrates an organization's clear commitment to quality and continuous improvement.

The URAC-accredited health plan:

  • Provides accurate and clear communications to members
  • Documents the geographic and demographic make-up of their enrollee populations and creates provider networks accessible to the communities they seek to serve and deliver quality care.
  • Continuously reviews and improves quality and safety of care
  • Ensures that providers are credentialed per national standards
  • Ensures the availability of a sufficient number and types of providers, including policies for accessing emergency and out of network coverage
  • Does not deny access to services on grounds other than medical necessity (plans are barred from rewarding employees for denying care)
  • Allows only qualified professionals to make medical necessity decisions based on the latest clinical guidelines
  • Provides guidance and educational support for obtaining plan services in language that respects members’ diverse backgrounds
  • Collects members’ opinions on their care and level of service for quality improvement purposes
  • Gives members access to complaint and appeal processes
  • Keeps members’ personal health information confidential
  • Offers mental health services and physical health services on an equal basis
  • And more.

URAC’s Health Plan Accreditation focuses on quality improvement activities that promote patient safety across the continuum of care:

  • Wellness and Health Promotion
  • Care Coordination
  • Medication Safety and Care Compliance
  • Rewarding Quality
  • Care delivery through a Patient Centered Health Care Home Network
  • Mental Health Parity
  • HIPAA Breach Requirements
  • Measures – patient centeredness, communication and care coordination, patient safety, community, population and public health, efficiency and cost reduction, effectiveness of clinical care
  • Patient experience of care (CAHPS® Survey)

URAC’s Health Plan Accreditation Clinical Quality Measures are aligned closely with the six National Quality Measure Domains identified in the HHS National Quality Strategy.

Download our Health Plan Standards-at-a-Glance.

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