Instructions for 2015 Plan Year Accreditation Requirements and Submission of Quality Assurance and Improvement Plans

Minnesota Statutes, Section 62K.09 outlines requirements for accreditation requirements for carriers offering individual and small group products on and off MNsure:

62K.09 ACCREDITATION STANDARDS.

(a) A health carrier that offers any individual or small group health plans in Minnesota outside of MNsure must be accredited in accordance with this subdivision. A health carrier must obtain accreditation through URAC, the National Committee for Quality Assurance (NCQA), or any entity recognized by the United States Department of Health and Human Services for accreditation of health insurance issuers or health plans by January 1, 2018. Proof of accreditation must be submitted to the commissioner of health in a form prescribed by the commissioner of health.

(b) A health carrier that rents a provider network is exempt from this subdivision, unless it is part of a holding company as defined in section 60D.15 that in aggregate exceeds ten percent market share in either the individual or small group market in Minnesota.

Subd. 2.Accreditation; MNsure.

(a) MNsure shall require all health carriers offering a qualified health plan through MNsure to obtain the appropriate level of accreditation no later than the third year after the first year the health carrier offers a qualified health plan through MNsure. A health carrier must take the first step of the accreditation process during the first year in which it offers a qualified health plan. A health carrier that offers a qualified health plan on January 1, 2014, must obtain accreditation by the end of the 2016 plan year.

(b) To the extent a health carrier cannot obtain accreditation due to low volume of enrollees, an exception to this accreditation criterion may be granted by MNsure until such time as the health carrier has a sufficient volume of enrollees.
Subd. 3.Oversight.

A health carrier shall comply with a request from the commissioner of health to confirm accreditation or progress toward accreditation.

Subd. 4.Enforcement.

The commissioner of health shall enforce this section.

Minnesota Statutes, Section 62K.12 outlines requirements for submission of quality assurance and improvement programs for carriers offering individual and small group products offered on and off MNSure:

62K.12 QUALITY ASSURANCE AND IMPROVEMENT.
Subdivision 1.General.

(a) All health carriers offering an individual health plan or small group health plan must have a written internal quality assurance and improvement program that, at a minimum:

(1) provides for ongoing evaluation of the quality of health care provided to its enrollees;

(2) periodically reports the evaluation of the quality of health care to the health carrier's governing body;

(3) follows policies and procedures for the selection and credentialing of network providers that is consistent with community standards;

(4) conducts focused studies directed at problems, potential problems, or areas with potential for improvements in care;

(5) conducts enrollee satisfaction surveys and monitors oral and written complaints submitted by enrollees or members; and

(6) collects and reports Health Effectiveness Data and Information Set (HEDIS) measures and conducts other quality assessment and improvement activities as directed by the commissioner of health.

Subd. 2.Exemption.

A health carrier that rents a provider network is exempt from this section, unless it is part of a holding company as defined in section 60D.15 that in aggregate exceeds ten percent market share in either the individual or small group market in Minnesota.

Subd. 3.Waiver.

A health carrier that has obtained accreditation through the URAC for network management; quality improvement; credentialing; member protection; and utilization management, or has achieved an excellent or commendable level ranking from the National Committee for Quality Assurance (NCQA), shall be deemed to meet the requirements of subdivision 1. Proof of accreditation must be submitted to the commissioner of health in a form prescribed by the commissioner. The commissioner may adopt rules to recognize similar accreditation standards from any entity recognized by the United States Department of Health and Human Services for accreditation of health insurance issuers or health plans.

Subd. 4.Enforcement.

The commissioner of health shall enforce this section.

2015 Plan Year Recertification instructions for QHP Carriers

Please note that it is not necessary for all affiliated entities to be accredited as long as one of the affiliates is accredited. However, the non-accredited affiliate must use the same quality assurance and improvement program as the accredited affiliate. For example, if the HMO is accredited and the insurance company is not, the accreditation standard may still be met as long as the entity issuing the product uses the same quality assurance program as the HMO.

For QHP carriers seeking recertification, the following accreditation instructions apply:

  1. If the QHP carrier or its affiliate is already accredited by NCQA or URAC under either an HMO or insurance license, please use the corresponding accreditation template in SERFF.
  2. The templates can be found at: http://www.serff.com/plan_management_data_templates.htm (NCQA template 1.6 and URAC template 1.4)
  3. If neither  the QHP carrier nor its affiliate(s) is  accredited by NCQA or URAC, please submit the following documentation under the “supporting documents” tab in SERFF demonstrating that the carrier has taken the first step toward accreditation:
    1. A narrative description of the plan to gain accreditation and any actions taken toward accreditation; 
    2. Timelines for completion of each step of accreditation;
    3. Person(s) responsible for each step; and  
    4. If the carrier claims an exception to accreditation requirements due to low volume of enrollees, please submit documentation supporting low expected enrollment.
  4. Please note that this year under the “Company and Contact” tab of the binders, there is a space to include accreditation information, if such information is available.
  5. In addition, all carriers must submit a written internal quality and improvement program that meets the requirements of 62K.12 to the “supporting documents” tab of SERFF, unless:
    1. The carrier has obtained accreditation through URAC for network management; quality improvement; credentialing; member protection; and utilization management, or has achieved an excellent or commendable level ranking from the NCQA.
    2. The written internal quality and improvement plan must include documentation that the program:
      1. provides for ongoing evaluation of the quality of health care provided to its enrollees;
      2. periodically reports the evaluation of the quality of health care to the health carrier's governing body;
      3. follows policies and procedures for the selection and credentialing of network providers that is consistent with community standards;
      4. conducts focused studies directed at problems, potential problems, or areas with potential for improvements in care;
      5. conducts enrollee satisfaction surveys and monitors oral and written complaints submitted by enrollees or members; and
      6. collects and reports Health Effectiveness Data and Information Set (HEDIS) measures and conducts other quality assessment and improvement activities as directed by the commissioner of health.

Instructions for Carriers Seeking to Offer New Individual and Small Group Products on MNsure

Please note that it is not necessary for all affiliated entities to be accredited as long as one of the affiliates is accredited. However, the non-accredited affiliate must use the same quality assurance and improvement program as the accredited affiliate. For example, if the HMO is accredited and the insurance company is not, the accreditation standard may still be met as long as the entity issuing the product uses the same quality assurance program as the HMO.

  1. New carriers submitting QHP binders to SERFF do not need to submit accreditation information for operation in the first plan year, but will be required to submit accreditation information in the second plan year.  
  2. Please note that this year under the “Company and Contact” tab of the binders, there is a space to include accreditation information, if such information is available.
  3. New carriers must submit a written internal quality and improvement program that meets the requirements of 62K.12 to the “supporting documents” tab of SERFF, unless:
    1. The carrier has obtained accreditation through URAC for network management; quality improvement; credentialing; member protection; and utilization management, or has achieved an excellent or commendable level ranking from the NCQA.
    2. The written internal quality and improvement plan must include documentation that the program:
      1. provides for ongoing evaluation of the quality of health care provided to its enrollees;
      2. periodically reports the evaluation of the quality of health care to the health carrier's governing body;
      3. follows policies and procedures for the selection and credentialing of network providers that is consistent with community standards;
      4. conducts focused studies directed at problems, potential problems, or areas with potential for improvements in care;
      5. conducts enrollee satisfaction surveys and monitors oral and written complaints submitted by enrollees or members; and
      6. collects and reports Health Effectiveness Data and Information Set (HEDIS) measures and conducts other quality assessment and improvement activities as directed by the commissioner of health.

Instructions for Carriers Offering Individual and Small Group Products off MNsure

Please note that it is not necessary for all affiliated entities to be accredited as long as one of the affiliates is accredited. However, the non-accredited affiliate must use the same quality assurance and improvement program as the accredited affiliate. For example, if the HMO is accredited and the insurance company is not, the accreditation standard may still be met as long as the entity issuing the product uses the same quality assurance program as the HMO.

  1. If the carrier is already accredited by NCQA or URAC under either an HMO or insurance license, please use the corresponding accreditation template in SERFF when submitting the plan management binder.
  2. Please note that this year under the “Company and Contact” tab of the binders, there is a space to include accreditation information, if such information is available.
  3. If the carrier is not accredited, carrier must be accredited by NCQA and URAC and submit proof of accreditation with individual and small group binders for the 2018 plan year.
  4. All carriers must submit a written internal quality and improvement program that meets the requirements of 62K.12 to the “supporting documents” tab of SERFF, unless:
    1. the carrier has obtained accreditation through URAC for network management; quality improvement; credentialing; member protection; and utilization management, or has achieved an excellent or commendable level ranking from the NCQA.
    2. The written internal quality and improvement plan must include documentation that the program:
      1. provides for ongoing evaluation of the quality of health care provided to its enrollees;
      2. periodically reports the evaluation of the quality of health care to the health carrier's governing body;
      3. follows policies and procedures for the selection and credentialing of network providers that is consistent with community standards;
      4. conducts focused studies directed at problems, potential problems, or areas with potential for improvements in care;
      5. conducts enrollee satisfaction surveys and monitors oral and written complaints submitted by enrollees or members; and
      6. collects and reports Health Effectiveness Data and Information Set (HEDIS) measures and conducts other quality assessment and improvement activities as directed by the commissioner of health.

 

Updated Thursday, May 08, 2014 at 04:02PM