Effective for Surveys Beginning On or After July 1, Standards and Guidelines for Accreditation and Certification in Wellness & Health Promotion

Transcription

1 Effective for Surveys Beginning On or After July 1, 2016 Standards and Guidelines for Accreditation and Certification in Wellness & Health Promotion

2 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without the written permission of NCQA by the National Committee for Quality Assurance th Street NW, Third Floor Washington, DC All rights reserved. Printed in the U.S.A. NCQA Customer Support: NCQA Fax: NCQA Web Site: NCQA Policy Clarification Support via Internet at: Item #

3 Acknowledgments Acknowledgments NCQA is pleased to release the 2016 Standards and Guidelines for the Accreditation of Wellness and Health Promotion Organizations, effective for surveys beginning on or after July 1, The Standards and Guidelines are available on the Web-based Interactive Survey System (ISS), Interactive Review tool (IRT) and in e-pub format. The ISS system is designed to help organizations prepare for survey and make the survey process more efficient. Updating the Standards and Guidelines would not have been possible without a team effort by the staff of the following NCQA departments: Product Design and Support, Accreditation and Recognition Operations, Performance Measurement, Information Technology and Information Products and Public Policy and Communications. The WHP Advisory Committee, NCQA Standards Committee, Committee on Performance Measurement, Review Oversight Committee, Purchaser Advisory Council, Consumer Advisory Council, advisory committees and surveyors also shared their insights to help enhance NCQA s Wellness & Health Promotion Accreditation program. In addition, NCQA received invaluable input from health plans, purchasers, consumers, policy makers and others who offered suggestions during the Public Comment period. Sincerely, Margaret E. O Kane President, NCQA Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

4 Acknowledgments Standards Committee John Fallon, MD (Chair) Blue Cross Blue Shield of Massachusetts Andy Baskin, MD Aetna Barbara Caress Independent Consultant Sabrina Corlette, JD Georgetown University Health Policy Institute Chris Dennis, MD, MBA, FAPA Landmark Health Elizabeth Goldstein, PhD Centers for Medicare & Medicaid Services Kathleen Harris, MPH Time Warner, Inc. Alice Lind, RN, MPH Washington State Healthcare Authority Wendy Long, MD, MPH Health Care Finance and Administration State of Tennessee Kevin McCabe, MD SC Johnson & Son, Inc. Gordon Norman, MD Towers Watson Kirsten Sloan American Cancer Society Action Network, Inc. Ilene Stein SEIU Susan S. Stuard, MBA Lakefleet Consulting Liaisons Victor Caraballo, MD, MBA Independence Blue Cross Kirstin Dawson, MS America s Health Insurance Plans Carole Redding Flamm, MD, MPH Blue Cross BlueShield Association Pamela Greenberg, MPP Association for Behavioral Health and Wellness Deborah Kilstein, MBA, RN Association for Community Affiliated Plans Anne Mutti Mathematica Policy Research 2016 WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

5 Acknowledgments WHP Advisory Committee Jeff Harris, MD, MPH, MBA (Chair) University of Washington David Anderson, PhD, LP StayWell Health Management Alan Balch, PhD Preventive Health Partnership Jeff Dobro, MD RedBrick Health Jim Giuffré Healthwise Jeffrey R. Harris, MD, MPH, MBA University of Washington, Health Promotion Research Center John Harris, Med, FAWHP Performance ph J. Douglas Knoop, MD, MHA, FACS, CPE Healthstat, Inc. Karen Moseley Care Continuum Alliance Nirmal Patel, MD Cisco Systems, INC Steve Sleigh IAM National Pension Fund Kirsten Sloan National Partnership for Women & Families Andrew Steele, MD, MPH, MSc Denver Health JoAnn Volk, MA Georgetown Health Policy Institute Peter Wald, MD, MPH USAA Liaisons Pamela Greenberg, MPP Association for Behavioral Health and Wellness Lydia Mitts Families USA Myrtho Montes, MD Prudential Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

6 2016 WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

7 Table of Contents Table of Contents Overview Notable Changes for Wellness and Health Promotion: Accreditation and Certification Products... 1 What Is Wellness and Health Promotion?... 1 The Scope of Evaluation... 1 The Value of Accreditation and Certification... 2 The WHP Standards... 2 Wellness and Health Promotion Certification Programs... 4 The Value of Certification... 4 A Standard s Structure... 4 Eligible Individual and Client Organization... 6 Where to Find Specific Information... 7 Other Important NCQA Information... 8 Other NCQA Programs... 8 Policies and Procedures Section 1: Eligibility and the Application Process Evaluation Options Eligibility for Accreditation and Certification How NCQA Determines Eligibility for WHP Accreditation/Certification How NCQA Defines a WHP Organization for Accreditation/Certification Right to Decline a Survey Applying for an NCQA Survey Organization Obligations Section 2: Accreditation, Scoring and Status Requirements Accreditation and Certification Surveys Status Descriptions and Seals Determining Accreditation and Certification Status How Organizations Are Evaluated Scoring Guidelines Must-Pass Elements Other Information NCQA May Consider Notification to Regulatory Agencies Section 3: The Survey Process About the Survey Process Survey Results and Scoring Reconsideration Subsequent Survey Section 4: WHP Performance Measure Results AWPR Status Option to Upgrade to AWPR Status WHP Performance Measure Descriptions Section 5: Reporting Results Reporting Results Reporting Accreditation or Certification Status to the Public NCQA WHP Report Card Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

8 Table of Contents Section 6: Additional Information Complaint Review Process Reporting Hotline for Fraud and Misconduct Notifying NCQA of Reportable Events Discretionary Survey Suspending Accreditation or Certification Revoking Accreditation or Certification Mergers and Acquisitions Lapse in Accreditation or Certification Status Privacy, Security and Confidentiality Requirements Revisions to Policies and Procedures Disclaimer WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

9 Overview 1 Overview Notable Changes for 2016 Restructured and clarified the Standards and Guidelines: Revised the language in the scope of review. Reorganized the explanation and examples by factor. Simplified content and removed ambiguity. Consolidated appendices for delegation and automatic credit into one appendix. Wellness and Health Promotion: Accreditation and Certification Products NCQA Accreditation/Certification demonstrates to health plans, employers, regulators and consumers that an organization follows industry best practices for providing high-quality wellness services. NCQA strongly supports high-value programs that increase wellness and health. The NCQA WHP program reflects the most current definition of a high-value, industry-leading wellness program: a program that successfully engages individuals in improving their health. The program draws on the expertise of multiple stakeholders, including consumer advocates, business coalitions, industry leaders and researchers. WHP organizations that offer the full range of wellness services are eligible for NCQA Accreditation. Organizations that offer niche programs or products to support an overall wellness strategy are eligible for NCQA Certification. What Is Wellness and Health Promotion? Wellness and health promotion (WHP) programs are designed to help eligible individuals optimize their health by assessing their health status and providing them with steps to mitigate their modifiable risk factors. Programs typically include these key elements: Health appraisals (HA). Lifestyle and educational materials about a specific health condition or illness. Online or onsite wellness classes, activities and educational resources. Personal coaching. Health fairs. Gym discounts. Support for employees facing increased risks associated with health and lifestyle-related habits (i.e., diet, smoking and tobacco use, stress). These program elements can be offered by an independent vendor or by a health plan. The Scope of Evaluation NCQA offers evaluation options for NCQA Accreditation and NCQA Certification. Organizations eligible for evaluation include wellness and health promotion vendors, health plans, managed behavioral healthcare organizations (MBHO) and disease management (DM) organizations. The WHP program focuses on services provided by the organization, not on the type of organization. NCQA aligned the WHP program with the expectations of employers and health plans that contract for wellness and health promotion services and with the expectations of consumers who use wellness services. The program provides a basis for comparison among organizations. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

10 2 Overview The Value of Accreditation and Certification Accredited/certified organizations have found: NCQA WHP Accreditation/Certification can be used as a differentiator. Most employers recognize that the NCQA seal means an organization is dedicated to quality improvement and value and understands the importance of measuring quality and outcomes. WHP accreditation/certification helps organizations structure their wellness programs and processes and provides a quality check. The WHP program reviews areas in high demand by employers and other clients, and helps organizations prepare for and succeed on request for proposals and performance-based contracts. The WHP program is flexible and lets organizations customize the review for the way they sell their products. The WHP program focuses on high-impact health and wellness problems with a strong evidence base, like achieving a healthy weight, quitting tobacco use and engaging in physical activity. It does not call for screenings and tests that are not grounded in evidence. For employers and purchasers, NCQA Accreditation/Certification: Confirms use of industry best practices. Saves time. An independent entity (NCQA) has already assessed and evaluated the program, so purchasers can focus on their unique needs. Identifies progressive organizations that are committed to continuous quality improvement. NCQA posts detailed information on vendors and their accreditation results in a free report card on its Web site. Employers that want to use strong incentives for participation in wellness and health promotion are required by the Affordable Care Act to have a reasonably designed program. In the regulations implementing this requirement, the federal government recommended accreditation based on evidence, increasing the likelihood of program success. 11 The WHP Standards NCQA WHP Accreditation involves a thorough review of WHP program content and engagement activities associated with a WHP program, with a focus on alignment with best practices and protecting consumer information and rights. The program has 12 standards; specific elements address how organizations can demonstrate compliance with accreditation expectations. WHP 1: Client Organization Engagement WHP 2: Data Exchange and Integration WHP 3: Privacy and Confidentiality The organization assesses the client organization s wellness and health promotion activities and provides education, recommendations and guidance for an effective WHP program. For example, the organization shares information with an employer about incentives (e.g., their advantages, disadvantages and effectiveness), or an employer provides the organization with information on its employees language needs. The organization shares information with client organizations about its data integration capabilities. The organization is transparent about the types of data exchanged and types of organizations with which data are shared. The organization protects the confidentiality of eligible individuals personal health information (PHI). 1 Federal Register, June 3, WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

11 Overview 3 WHP 4: Engaging the Population WHP 5: Health Appraisals WHP 6: Identification and Targeting WHP 7: Self- Management Tools WHP 8: Health Coaching WHP 9: Rights and Responsibilities WHP 10: Measuring Effectiveness Accreditation WHP 11: Incentive Management WHP 12: Reporting WHP Performance WHP 13: Measuring Effectiveness Certification WHP 14: Delegation of WHP Activities The organization offers services to increase health awareness and opportunities for engagement. Services are based on evidence of effectiveness. Materials are up to date (i.e., updated every two years, or more often, if new evidence is available) and are offered in a variety of formats (i.e., online, in print and by telephone). The organization helps eligible individuals manage their health through HAs and HA results, and by disclosing how it uses HA information and how it protects privacy. Standards address the demographic, health and wellness information that must be included in the HA. The organization identifies the wellness and health promotion needs of eligible individuals and develops targeted activities to address those needs; for example, targeted recommendations for preventive screenings based on information gathered by the HA. The organization has evidence-based self-management tools to help individuals manage their health. Standards address topics that tools must focus on; call for periodic testing to make sure tools are usable; require review and update of tools to reflect changes in evidence; and require the organization to make tools available in different formats. The organization provides coaching services to help individuals develop skills to make healthy choices and improve their health. Standards address training and monitoring of coaches and require the organization to refer individuals to other resources, if necessary, such as disease management programs. The organization maintains written policies and procedures addressing the rights of eligible individuals and the complaint process, and discloses information about its marketing, advertising and sponsorship relationships. An organization undergoing an Accreditation Survey has a quality improvement process to evaluate program effectiveness, and identifies, measures and acts on opportunities to improve its processes and outcomes. The organization uses quality measures and participant experience results to evaluate its performance and works continually to improve its program and services. The organization discloses its capability to manage client organizations incentive programs (including monetary and nonmonetary rewards), and evaluates the effects of incentive programs it manages at least every two years. The organization measures its performance using NCQA WHP Performance Measures (drawn from HA results) and submits audited measure results to NCQA annually. An organization undergoing a Certification Survey has a quality improvement process to evaluate program effectiveness, and identifies, measures and acts on opportunities to improve its processes and outcomes. If an organization delegates functions or activities, it remains accountable for ensuring that the functions or activities meet NCQA requirements and that it has appropriate oversight structures and mechanisms. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

12 4 Overview Wellness and Health Promotion Certification Programs For organizations whose wellness programs are more limited in scope, NCQA offers certification options for the following products: Health Appraisal. Self-Management Tools. Health Coaching. Standards are the same as for the NCQA WHP Accreditation program related to specific components. Organizations must also meet standards for maintaining privacy and confidentiality (WHP 3) and for measuring effectiveness (WHP 13). The Value of Certification Organizations that earn NCQA WHP Certification are positioned to: Obtain contracts with comprehensive vendors or health plans that ask for NCQA Certification. Provide clients with automatic credit toward their accreditation. Distinguish themselves from the competition. A Standard s Structure Each standard includes most of the following components. Standard statement Intent statement Summary of changes Element Factor Scoring States acceptable performance or results. States the goal of the standard. Revisions to the standards and guidelines from 2014 to The Summary of Changes is organized into three categories. 1. Additions New requirements. 2. Deletions Retired requirements. 3. Clarifications Revisions based on frequently asked questions from customers, surveyors and NCQA staff. The scored component of a standard that provides details about performance expectations. NCQA evaluates each element to determine how well the organization meets the standard s requirements. Each element has a point value; the total point value for a standard is the sum of the point values for each element. Each standard comprises one or more elements. A scored item in an element. For example, an element may require the organization to demonstrate that its policies and procedures include four specific items; each item is a factor. Not all elements have factors. The level of performance the organization must demonstrate to receive a specified percentage of element points. Each element has up to five possible scoring levels (100%, 80%, 50%, 20% and 0%). For each element, scoring specifies factors or other aspects of the element that the organization must meet to achieve each percentage of points. Many elements do not have all five scoring levels; some may have only two (100% and 0%) WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

13 Overview 5 A scoring level that does not apply to an element is indicated by No scoring option in the appropriate box. Refer to Appendix 1: Standard Points for If an element is scored NA, its points are allocated proportionally to the other elements in the standard, based on their point values. Data source Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA defines four types of data sources. 1. Documented process Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization. 2. Reports Aggregated sources of evidence of action or performance for an element, including program evaluation management reports; key indicator reports; summary reports from member reviews; system output information; minutes; and other documentation of actions that the organization has taken. 3. Materials Prepared content that the organization provides to its eligible individuals and client organizations, including written and electronic communication; Web sites; scripts; brochures; and contracts or agreements with delegates and vendors. 4. Records or files Actual records or files, such as eligible individual files, that show direct evidence of action or performance for an element. If an element lists multiple data sources, the scope of review specifies the evidence needed to meet the requirements. Scope of review The extent of the organization s services evaluated during an NCQA Survey. The scope of review for each element describes the types of documentation NCQA examines for each option. NCQA reserves the right to request additional documentation if necessary to assess the organization s performance. NCQA reviews and scores each element once for the organization, unless otherwise specified. Look-back period Expanding the look-back period Meeting the lookback period for a documented process The period for which the organization must demonstrate performance against NCQA requirements. NCQA measures the look-back period from the point of submission of the completed survey tool. Unless otherwise noted, the organization must meet requirements throughout the look-back period. For example, for most non-file review elements, if the look-back period is 24 months and the survey date is July 10, 2016, the organization must show evidence that requirements were met at all times, from the survey date back to any date in July Under certain circumstances, NCQA may expand the look-back period; for example, if it is necessary for an organization to demonstrate that performance requirements were met and to produce an adequate sample for file reviews. The organization provides evidence that its policies and procedures or other documented processes met the requirements throughout the look-back period. If there were no changes to policies and procedures or other documented processes during the look-back period, the organization submits the current document. If the organization changed its documented process during the look-back period to meet a NCQA requirement, it can provide: Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

14 6 Overview The current version of the policies and procedures or other documented process, with cited revisions and approval dates, or The current version and the version in place at the start of the look-back period. NCQA may request additional clarification and documentation if there are multiple revisions to a documented process during the look-back period. The organization can demonstrate that it reviewed and updated a policy by including the effective date and subsequent revision dates in a header, cover sheet or addendum. Meeting the lookback period for reports or materials Meeting the lookback period for records and files Explanation Exception The organization provides evidence that reports or materials were produced at the frequency specified in the element. If no frequency is specified, the organization provides evidence that it completed the required reports or produced the required materials within the look-back period stated in the scope of review. For file review elements, the organization must meet the look-back requirements specified in the element. Specific requirements that the organization must meet, and guidance for demonstrating performance against the element. A requirement, or part of a requirement, that does not apply under specific circumstances. NCQA lists exceptions at the end of each element s Explanation section in the Standards and Guidelines. For most exceptions, organizations must provide evidence that they meet criteria for an NA score. If an organization believes an NA score is warranted because of a regulatory conflict, it must bring this to NCQA s attention and submit validating evidence. Related information Examples This subsection addresses special situations that may arise relative to the requirements and provides important information to help organizations save time and resources. Not every element has the Related information section. Information illustrating performance against an element s requirements. Examples are for guidance only and are not requirements or all-inclusive. Not all elements have examples. Eligible Individual and Client Organization An eligible individual is qualified to participate in any aspect of an organization s WHP program. A client organization is an entity (e.g., employer or plan sponsor, health plan, provider organization, other client) that contracts with the organization to provide wellness and health promotion services WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

15 Overview 7 Where to Find Specific Information The Standards and Guidelines include the policies and procedures, standards and elements, scoring guidelines and appendices. Policies and Procedures Information on organizations eligible for NCQA WHP Accreditation/Certification. Information on applying for NCQA WHP Accreditation/Certification. Responsibilities of organizations seeking accreditation/certification. Information on survey types. Information on determining accreditation status. Information on must-pass elements. Information on the Survey process. Information on the survey tool and readiness evaluation. Information on the Reconsideration process. WHP performance measure results for Accredited With Performance Reporting (AWPR) status. Information on the annual performance measures submission. WHP performance measure descriptions. Information on reporting accreditation results to organizations and to the public. Accreditation and Certification Standards The standards, elements and factors. A summary of changes from the previous standards year. Scoring guidelines describing requirements for each standard, element and factor. Information about how an organization can demonstrate performance against the element s requirements. Data sources used to demonstrate compliance with requirements. The scope of review. The look-back period. An explanation of expectations for demonstrating performance against the element s requirements. Examples. Appendices Appendix 1: Summary table of points for the standards and elements. Appendix 2: Summary tables of WHP accreditation and certification product options. Appendix 3: Summary of changes for Appendix 4: Delegation and automatic credit guidelines. Appendix 5: Merger, Acquisition and Consolidation Policy. Appendix 6: Glossary. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

16 8 Overview Other Important NCQA Information NCQA publications, user groups and educational programs facilitate the evaluation process. They help plans succeed by making the path to performance-based accreditation and certification accessible and feasible. In addition to the Interactive Survey System (ISS) and Interactive Review Tool (IRT), NCQA provides a variety of information to help organizations prepare for Accreditation and Certification Surveys. NCQA produces many publications relevant to organizations. Call NCQA Customer Support at or go to the NCQA Web site ( Access policy clarifications from the NCQA Policy Clarification Support (PCS) system at General questions are usually answered within 2 business days; complex questions are usually answered within 30 days. Find corrections, clarifications and policy changes to this publication at icationspolicychanges.aspx. Find frequently asked questions (FAQ) at FAQs are updated on the 15th of the month or on the first business day following the 15th of the month. Organizations that are involved in NCQA Accreditation and Certification activities are encouraged to join the Accreditation and Certification Users Group (ACUG). The ACUG provides a learning and development platform for members to discuss and apply updates to their organizations' procedures. Membership benefits include monthly newsletters, WebEx discussions, and vouchers for publications, educational conferences and Quality Compass. For more information, acug@ncqa.org or go to for a full description of the program. NCQA educational seminars provide valuable information on NCQA standards, the survey process and performance measures. Course offerings range from a basic introduction to NCQA standards and performance measures to advanced techniques for quality improvement. Visit the NCQA Web site or call NCQA Customer Support at NCQA staff are available to help organizations determine which product is most suitable based on eligibility and program structure. Staff provide step-by-step guidance on the application process, which includes an overview of policies and procedures, fee structure, timelines and survey preparation. Contact ApplicationsandScheduling@ncqa.org. Other NCQA Programs NCQA offers the following accreditation programs: Accountable Care Organizations (ACO). Case Management (CM). Disease Management (DM). Health Plan (HP). Managed Behavioral Healthcare Organization (MBHO). NCQA offers the following certification programs: Credentials Verification Organization (CVO). Disease Management (DM). Health Information Products (HIP). Physician and Hospital Quality (PHQ). Utilization Management and Credentialing (UM/CR) WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

17 Overview 9 NCQA offers the following recognition programs: Diabetes Recognition (DRP). Heart/Stroke Recognition (HSRP). Patient-Centered Connected Care. Patient-Centered Medical Home (PCMH 2011). Patient-Centered Specialty Practice (PCSP). NCQA offers the following evaluation programs: New York Ratings Examiner Reviews (NYRx). NCQA offers the following distinction programs: Multicultural Health Care (MHC). Patient Experience Reporting (for NCQA-Recognized PCMHs). Note: Organizations that contract with NCQA-Accredited/Certified organizations can reduce their delegation oversight. Refer to Appendix 4: Delegation and Automatic Credit Guidelines. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

18 WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

19 Policies and Procedures

20 WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

21 Policies and Procedures Section 1: Eligibility and the Application Process 13 Section 1: Eligibility and the Application Process Summary of Changes November 20, 2017: Updated the NCQA address to th Street NW, Third Floor Washington DC, under Applying for an NCQA Survey Application request. Added a note under Organization Obligations that Discretionary Surveys review the organization against the standards in effect at the time of the Discretionary Survey. Evaluation Options An Evaluation Option is defined by its distinct combination of requirements, scoring, statuses and length of accreditation or certification. NCQA WHP Accreditation and Certification has five Evaluation Options: 1. WHP Accreditation. 2. WHP Accreditation With Performance Reporting. 3. WHP Certification Health Appraisal. 4. WHP Certification Self-Management Tools. 5. WHP Certification Health Coaching. Table 1: Summary of survey type, eligibility, status and status duration Survey Types Eligibility Potential Accreditation/ Certification Status Status Duration Initial Organizations new to NCQA Accreditation/Certification or whose NCQA Accreditation/Certification status expired more than 2 years ago. Accredited AWPR Certified Denied Up to 24 months Up to 36 months Up to 24 months Renewal Organizations with current NCQA Wellness and Health Promotion Accreditation or Certification. Accredited AWPR Certified Denied Up to 24 months Up to 36 months Up to 24 months The organization progresses through the survey types in order of option from Initial Survey to Renewal Survey. After an organization has progressed to a Renewal Survey, all subsequent surveys will be for that survey type, unless the accreditation/certification status lapses for more than two years. Eligibility for Accreditation and Certification An organization that provides wellness and health promotion services can apply for an NCQA WHP Accreditation or Certification Survey if it meets the following criteria: Has a wellness and health promotion program that was in operation for a minimum of 90 days before submission of the survey tool. Is the legal entity that provides a wellness and health promotion program to client organizations. Provides a comprehensive wellness and health promotion program that offers a broad scope of services addressing a range of areas (e.g., healthy weight maintenance, smoking and tobacco use cessation, encouraging physical activity, managing stress, healthy eating, avoiding risky drinking, and identifying depressive symptoms) or provides wellness services in the domain for which they are seeking certification. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

22 14 Policies and Procedures Section 1: Eligibility and the Application Process Performs functions addressed in these standards and guidelines, either directly or through a service agreement. Complies with applicable federal, state and local laws and regulations, including requirements for licensure or registration. Operates without discrimination on the basis of sex, race, creed or national origin. Has a process for monitoring, evaluating and improving the quality and safety of services provided to eligible individuals and participants. How NCQA Determines Eligibility for WHP Accreditation/Certification WHP functions: Accreditation products Certification products NCQA considers the scope and function of the WHP services the organization provides. Organizations eligible for WHP accreditation are responsible for providing a comprehensive wellness program that offers a broad scope of services addressing a range of areas. Eligible organizations perform functions addressed in the accreditation product options in Appendix 2. Organizations eligible for WHP certification carry out some of the functions of the comprehensive wellness and health promotion program, but not all functions. Eligible organizations perform functions addressed in the certification product options in Appendix 2. How NCQA Defines a WHP Organization for Accreditation/Certification NCQA determines the appropriate entity, or entities, that must seek and obtain accreditation or certification status based on the legal entity, management structure and delivery system that supports the program NCQA accredits or certifies. NCQA considers the following structural factors when determining the accreditable or certifiable entity: Legal entity Centralization NCQA s goal is to identify the legal entity that provides a wellness and health promotion program to client organizations. NCQA considers the degree of centralization of key functions assessed by the accreditation standards. If key functions are decentralized, with distinct policies and procedures, NCQA may determine that there is more than one accreditable or certifiable entity. If the organization consists of multiple legal entities but otherwise operates as a single organization (i.e., same management structure; centralized key functions, including quality improvement and health coaching), NCQA awards accreditation or certification decisions for each legal entity. However, NCQA may evaluate centralized functions once and apply the results of the evaluation to each legal entity. Licensure NCQA considers licensure when defining an organization. The organization may have multiple licenses, especially if its service area crosses state lines WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

23 Policies and Procedures Section 1: Eligibility and the Application Process 15 Right to Decline to Survey Although NCQA makes every effort to determine that an organization meets the stated criteria in advance of a survey, NCQA reserves the right to decline to survey an organization, to suspend an ongoing survey or to withhold accreditation/certification, if it determines that the organization does not meet criteria. Applying for an NCQA Survey Application request Applications for Surveys can be ordered online at no charge at or by contacting NCQA Customer Support at: National Committee for Quality Assurance th Street NW, Third Floor Washington, DC Survey application The WHP organization submits a completed application that contains information about: The structure of the organization. Functions performed by the organization. Functions the organization delegates to other organizations. Preferred survey dates. This information helps NCQA structure a survey around the operational characteristics of the organization. Processing criteria NCQA only processes a complete application: The application and supporting attachments: The coverage area report. A signed current contract. The application fee. To avoid delays in application processing, organizations must request an application from the NCQA Publications Department no more than 30 days in advance of submitting the application materials. Application timeline Organizations should submit the complete application, application fee and signed Agreement a minimum of nine months before the desired survey date. If an organization submits materials less than nine months before the desired survey date, NCQA may not be able to accommodate the requested survey date. Note: Unless state or other applicable law requires modifications, all organizations are expected to sign NCQA s standard Agreement for NCQA Wellness & Health Promotion Survey. Requests to change the standard Agreement due to legal conflicts must be approved by NCQA, and must be submitted with evidence of the legal conflict at least 12 months before the requested survey date. Survey fee All pricing policies and survey fees are specified in Exhibit A of the Agreement for Survey. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

24 16 Policies and Procedures Section 1: Eligibility and the Application Process Organization Obligations By applying for WHP Accreditation/Certification and thereby applying for an NCQA survey, organizations agree to be bound by the Agreement for Wellness and Health Promotion Survey (the Agreement ). As part of the survey process, an organization must: Purchase a license to access and use the NCQA Web-based Interactive Survey System (ISS) Survey Tool. When the survey is in process access and use the Interactive Review Tool (IRT). Bring forth the entire WHP lines of business. The organization must include all eligible individuals including those in administrative services only (ASO) accounts for which the WHP organization offers or sells WHP services. If lines of business are handled differently, NCQA reviews the impacted elements separately and averages the scores of each. Report the required audited NCQA WHP performance measure results by the specified reporting date for the applicable standards year, if the organization seeks AWPR status. Continue to meet the requirements of the applicable NCQA Standards and Guidelines throughout the entire period an NCQA Accreditation/Certification status on those standards is valid. Note: If NCQA conducts a Discretionary Survey, it reviews the organization against the standards in effect at the time of the Discretionary Survey. The organization is obligated to complete the survey process once the survey begins WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

25 Policies and Procedures Section 2: Accreditation, Scoring and Status Requirements 17 Section 2: Accreditation, Scoring and Status Requirements Summary of Changes November 20, 2017: Added a new section regarding Add-On Surveys under the section Accreditation and Certification Surveys Renewal Surveys. Accreditation and Certification Surveys NCQA offers the following survey types to organizations seeking accreditation/certification. 1. Full Survey: Initial Survey. Renewal Survey. 2. Introductory Survey: Introductory Initial Survey. Introductory Follow-Up Survey. 3. Expedited Survey. Full Survey Initial Survey During a Full Survey, NCQA evaluates the organization against all of the WHP standards. The survey process for Full Surveys is outlined in Section 3: The Survey Process. Programs that have never completed a Full Survey undergo an Initial Survey. During an Initial Survey, NCQA evaluates the organization against all standards and scores each element. NCQA gives the organization final results that include performance against standards and elements and the awarded status. The organization has 30 calendar days from receipt of the results to accept or decline the status. The look-back period for Initial Surveys is shorter than for Renewal Surveys. Renewal Survey Before an organization s status expires, it must complete another Agreement, submit all requisite fees and undergo a Full Survey, called a Renewal Survey. Each time an organization receives survey results, NCQA assigns a date for the next survey. Even if the organization s WHP programs remain the same over time, it can receive a lower determination on a Renewal Survey if its programs have not kept pace with increased participant growth, if the organization has not adapted to changes in accreditation/certification standards or has not performed annual activities for standards that require it. NCQA uses the standards in effect at the time of the Renewal Survey, not those in effect during the original survey. Add-On Survey The Add-On Survey is required when an organization adds a new program to an existing accreditation/certification status. NCQA reviews relevant standards and elements for the new program under the same standards year as the existing accreditation/certification status. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

26 18 Policies and Procedures Section 2: Accreditation, Scoring and Status Requirements An organization may undergo an Add-On Survey only once during the accreditation/certification cycle. The look-back period for the Add-On Survey is six months. Introductory Survey Introductory Initial Survey The Introductory Survey option is available only to organizations seeking WHP accreditation/certification for the first time. An organization that was previously accredited/certified under the NCQA WHP program is not eligible for an Introductory Survey. Under an Introductory Survey, organizations may postpone a status result without penalty and may undergo up to two surveys before receiving a decision. The Introductory Initial Survey is a Full Accreditation/Certification Survey. The look-back periods are the same as for the Full Initial Survey. NCQA evaluates the organization against all standards and scores each element. Final results include performance against standards and the awarded status, which is based on the overall element score. The organization may accept or decline the accreditation/certification status (without penalty) at the completion of the survey and within 30 calendar days of receiving the results. An organization that declines its status may undergo an Introductory Follow-Up Survey on elements that did not receive a score of 100%. Declining status Organizations that decline an accreditation/certification status under the Introductory Survey option may accept scores that were 80% or 100% for specific elements and apply them toward an Introductory Follow-Up Survey on the remaining elements within 12 months of receipt of the Initial Survey report. The organization may also request Reconsideration of its status or scores, or it may decline the decision. Refer to Section 6: Additional Information. Introductory Follow-Up Survey An organization that declines its status has the option to undergo an Introductory Follow-Up Survey on elements that did not receive a score of 100%. Introductory Follow-Up Surveys must occur within 12 months of receiving Introductory Initial Survey results. The look-back period is 6 months. During the survey, NCQA reevaluates elements scored 50% or lower and elements scored 80% that an organization wants to include in the survey. The final score is a combination of the results of the Introductory Initial and Follow-Up Surveys. Accreditation/Certification status is based on the combined score. Organizations may only request Reconsideration for elements included in the scope of the Introductory Follow-Up Survey. Refer to Section 3. Expedited Survey Although an organization with Denied Accreditation/Certification status may not reapply for accreditation/certification until one year from the date of the Denied status, under some circumstances it may apply for a new survey in less than a year an Expedited Survey. NCQA determines whether an Expedited Survey is justified, based on the licensure consequences of accreditation/certification status and other factors, as appropriate. To qualify for an Expedited Survey, the organization must first submit a written request listing the steps it has taken to address the substantive issues that led to the Denied status. An Expedited Survey is a full-scope survey. It uses the standards in effect at the time of the Expedited Survey. The look-back period is six months. The organization is reviewed against the standards and guidelines in effect at the time of the Expedited Survey. The organization must provide documentation for all requirements. Documentation may have been submitted previously or may be 2016 WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016

27 Policies and Procedures Section 2: Accreditation, Scoring and Status Requirements 19 new. The organizations may bring forward new programs that were not included in the original submission. At its sole discretion, NCQA may grant a request for an Expedited Survey in less than one year if: The organization demonstrates it can resolve the issues identified in the original survey in less than one year. Correction of the issues would raise the organization s accreditation/ certification status in a new survey. Status Descriptions and Seals Accredited With Performance Reporting Accredited Certified Denied The organization s programs meet or exceed NCQA standards for wellness and health promotion, and the organization reported results for a specified number of NCQA WHP performance measures. This status is subject to revision from annual WHP performance measure results submission, and it is valid for up to three years from the date of the initial accreditation decision. The organization s programs meet or exceed NCQA standards for Wellness and Health Promotion Accreditation. This status is valid for up to two years from the date of the initial accreditation determination. The organization s programs meet or exceed NCQA standards for Wellness and Health Promotion Certification. This status is valid for up to two years from the date of the initial certification determination. The organization s programs did not meet the accreditation or certification requirements during the survey. An existing status remains in effect if an organization has a survey in process but a decision has not been made by the expiration date of the existing status. NCQA issues seals that reflect Accredited with Performance Reporting, Accredited or Certified status levels. Determining Accreditation and Certification Status Status and scoring The scoring range associated with each status is shown in the table below. Accreditation/certification is based on NCQA s assessment of an organization s compliance with the standards and elements, as well as on reporting of WHP performance measures. NCQA assesses performance against standards and elements individually and assigns a performance level of 100%, 80%, 50%, 20% or 0%. Organizations earn a percentage of element points based on the awarded performance level. The total point value for a standard is the sum of the point values for each element. Accreditation/certification status is based on the overall standards score. The ROC NCQA s Review Oversight Committee (ROC), an independent review committee composed of physicians external to NCQA, makes the final accreditation or certification status decision. NCQA incorporates the decision, as well as any changes recommended by the ROC, to generate the final results for the organization. NCQA results are not final until the ROC evaluates them. Effective for Surveys Beginning On or After July 1, WHP Standards and Guidelines

28 20 Policies and Procedures Section 2: Accreditation, Scoring and Status Requirements Accreditation Status AWPR Accredited Denied Certification Status Certified Health Appraisal Certified Self-Management Tools Certified Health Coaching Denied Standards Score points on accreditation standards. At least 80% on must-pass elements. At least 50% on WHP 12, Element A points on accreditation standards. At least 80% on must-pass elements Standards Score points. At least 50% on WHP 5: Health Appraisal. At least 50% on must-pass elements points. At least 50% on WHP 7: Self-Management Tools. At least 50% on must-pass elements points. At least 50% on WHP 8: Health Coaching. At least 50% on must-pass elements Minimum requirements NCQA does not round the numerical standards score when determining status. For example, an organization being surveyed for WHP Accreditation with a score of receives Denied status (scoring threshold of ). An organization that elects to market its status must do so in accordance with the NCQA Guidelines for Advertising and Marketing. How Organizations Are Evaluated NCQA evaluates organizations on their performance against accreditation/certification standards and submission of WHP performance measure results. An organization seeking accreditation/certification must: Identify the product it wants to have surveyed. Identified in the survey application and in the survey tool under the tab Set Up Survey Tool. Undergo a full-scope Accreditation Survey at least once every three years or a Certification Survey once every two years, to evaluate systems that support each identified program or condition against the applicable standards. To maintain Accredited With Performance Reporting status, submit applicable WHP performance measure results annually to NCQA by April 15. Scoring Guidelines NCQA uses the scoring guidelines to evaluate an organization s performance against each element. Each standard has a point value. Standards total 100 points. Refer to Appendix 1: Standard and Element Points for The scoring guidelines codify NCQA decision-making principles used to evaluate all organizations consistently against its standards and can help the organization prepare for a survey; they are not a substitute for the judgment of the ROC. NCQA recognizes that it is not possible to account for all the 2016 WHP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2016