NCQA stands for the National Committee for Quality Assurance, an independent nonprofit organization that evaluates and rates the quality of health plans and healthcare organizations in the United States. Founded in 1990, NCQA’s mission is straightforward: improve the quality of health care. It does this by setting standards, measuring performance, and publicly reporting results so that consumers, employers, and regulators can compare health plans on an even playing field. More than 200 million Americans, roughly 60% of the U.S. population, are enrolled in health plans that report quality data through NCQA’s measurement tools.
What NCQA Actually Does
NCQA operates as a kind of independent auditor for the healthcare system. It doesn’t deliver care or sell insurance. Instead, it creates standardized ways to measure whether health plans and providers are doing a good job, then holds them accountable by making the results public. Its founders described the goal as wanting to “turn on the lights” in an industry where consumers previously had no reliable way to compare quality across plans.
The organization’s work falls into three main areas: accreditation programs that certify health plans and provider organizations meet certain standards, performance measurement through a tool called HEDIS, and public ratings that score health plans so consumers can shop based on quality rather than just cost.
HEDIS: How Quality Gets Measured
HEDIS, short for the Healthcare Effectiveness Data and Information Set, is one of the most widely used performance measurement tools in American healthcare. It tracks whether health plans are actually delivering effective care by measuring specific, concrete outcomes: Are members getting recommended screenings? Are chronic conditions being managed well? Are patients following up after hospital stays?
The enrollment numbers show just how central HEDIS has become. As of 2021, over 200 million Americans were covered by plans reporting HEDIS data. That breaks down to about 114 million in commercial plans, 59 million in Medicaid managed care, nearly 25 million in Medicare Advantage, and 11.3 million in marketplace plans. When a health plan reports HEDIS results, it’s essentially opening its books to show whether its members are receiving high-quality care based on standardized benchmarks.
HEDIS is also evolving. The healthcare system is gradually shifting from manual data collection to digital quality measures, which pull data directly from electronic health records. This transition reduces the chance of human error, lowers administrative costs, and allows for faster quality assessments. Most HEDIS measures will eventually move to this electronic methodology.
Health Plan Accreditation
NCQA accreditation is a rigorous evaluation that health plans voluntarily undergo to demonstrate they meet nationally recognized standards. The accreditation process examines multiple dimensions of how a plan operates, including how it manages the use of medical services, how it credentials the doctors and hospitals in its network, how it handles case management for members with complex needs, and how it runs population health programs.
Several types of accreditation exist for different kinds of organizations:
- Health Plan Accreditation covers the broadest evaluation, with optional modules for Medicaid and long-term care services.
- Managed Behavioral Healthcare Organization accreditation evaluates organizations that coordinate mental health and substance use services, focusing on care quality, safety, access, and coordination between behavioral and medical care.
- Case Management for Long-Term Services is designed for community-based organizations that coordinate care for people with complex, ongoing needs.
Many state regulators and large employers require or prefer NCQA accreditation when contracting with health plans. For consumers, choosing an accredited plan offers some assurance that an independent third party has verified the plan meets quality and operational standards.
Health Plan Ratings and How They Work
NCQA publishes public ratings for commercial, Medicare, and Medicaid health plans. These ratings combine three sources of information: HEDIS performance data (clinical quality), CAHPS survey results (patient experience), and the plan’s NCQA accreditation status.
The CAHPS survey, which stands for Consumer Assessment of Healthcare Providers and Systems, measures how members actually experience their health plan. It captures things like how easy it is to get an appointment, whether providers communicate clearly, and how satisfied members are overall. Health plans seeking NCQA accreditation are required to conduct this survey and report the results.
Together, these three inputs give each plan a composite score. NCQA evaluates plans on the quality of care patients receive, how satisfied patients are, and how actively the plan works to improve over time. If you’re choosing between health plans during open enrollment, checking NCQA’s ratings is one of the more reliable ways to compare options based on objective data rather than marketing.
Patient-Centered Medical Home Recognition
Beyond health plans, NCQA also evaluates primary care practices through its Patient-Centered Medical Home (PCMH) program. A PCMH-recognized practice has demonstrated that it coordinates care around the patient rather than treating individual visits as isolated events. This means the practice tracks patients between appointments, manages chronic conditions proactively, and integrates behavioral health and specialty care.
Earning recognition isn’t a one-time event. Practices implement changes aligned with PCMH criteria, then undergo virtual reviews where evaluators provide feedback on what’s working and what needs improvement. Once recognized, the practice must submit evidence of ongoing quality improvement through annual reporting to maintain its status. For patients, choosing a PCMH-recognized practice generally means more coordinated, team-based care with fewer things falling through the cracks.
Health Equity Standards
NCQA has expanded its focus to include health equity through a dedicated accreditation program. Health Equity Accreditation evaluates whether organizations are collecting data on race, ethnicity, language, gender identity, and sexual orientation, then using that data to identify and reduce disparities in care. Organizations pursuing this accreditation must also demonstrate efforts to improve diversity within their own operations and reduce bias in how care is delivered.
An optional add-on called the “Plus” evaluation goes further, requiring organizations to assess and address social determinants of health like housing instability, food access, and transportation barriers. This represents a shift from measuring only clinical quality to recognizing that where and how someone lives directly shapes their health outcomes.
Why NCQA Matters to You
If you’ve ever compared health plans during open enrollment, used a star rating to pick a Medicare Advantage plan, or visited a primary care practice that seemed unusually well-organized, NCQA’s work was likely operating in the background. Its standards create financial and reputational incentives for health plans to invest in quality improvement rather than simply competing on price or network size.
The practical impact is real. When HEDIS measures track whether diabetic patients are getting their blood sugar monitored or whether children are receiving recommended vaccinations, health plans pay attention because their scores are public and affect their ability to win contracts. That accountability loop, where measurement drives improvement, is the core mechanism through which NCQA influences the care that millions of Americans receive.