This article explores the reasons why two groups of health maintenance organizations (HMOs) that serve rural areas have chosen to apply or not to apply for National Committee for Quality Assurance (NCQA) accreditation, and their future plans regarding accreditation. It also describes the challenges faced by HMOs serving rural areas in meeting NCQA accreditation standards and collecting Health Plan Employer Data and Information Set (HEDIS) data. A number of accredited HMOs cited positive benefits of the accreditation process, and most HMOs plan to apply or reapply for accreditation in the near future. Several HMOs identified challenges with accreditation standards, and the majority reported difficulty collecting some HEDIS measures. The HMOs identified a number of accreditation and HEDIS issues that are more problematic in rural areas.