NCQA Seeks Public Comment on Five Programs and the Use of AI in Health Care

February 25, 2025 · NCQA Communications

NCQA seeks feedback on five Accreditation and evaluation programs and the use of artificial intelligence (AI) in health care. Reviewers can submit comments to NCQA in writing via the Public Comment website by 5:00 p.m. (ET), Tuesday, March 25.

The public comment period includes the following programs and topics:

• Health Plan Accreditation.
• Long-Term Services and Supports (LTSS) Distinction for Health Plans.
• Utilization Management (UM) Accreditation.
• Managed Behavioral Healthcare Organization (MBHO) Accreditation.
• Patient-Centered Medical Home (PCMH) Recognition.
• Use of AI in Health Care.

About NCQA’s Public Comment

NCQA shares updates for public comment to generate thoughtful commentary and suggestions from interested parties. Many comments lead to changes in our standards and policies, and the review process makes our standards stronger for all stakeholders. NCQA asks respondents to consider whether the proposed requirements are feasible as written and are clearly articulated, and to highlight areas that might need clarification.

Summary of Proposed Changes

Below is a summary of the proposed changes to NCQA’s programs and standards. You can review the full details on NCQA’s website.

Health Plan Accreditation

Proposed updates to Health Plan Accreditation aim to align standards with the changing market landscape, stakeholder (states, employers, CMS, consumers) needs and regulatory requirements, and to assist organizations in their pursuit of quality care.

NCQA proposes updates to Health Plan Accreditation for 2026 in following areas:

• Data exchange and usability (QI).
• Payer-practitioner collaboration (PHM).
• Alternative payment model adoption (PHM).
• Utilization management and prior authorization (UM).
• Behavioral health network adequacy (NET).

Long Term Services and Supports Distinction for Health Plans

NCQA proposes to require organizations with LTSS Distinction in Health Plan Accreditation to annually submit data for four HEDIS LTSS measures, beginning June 2028, for surveys on or after July 1, 2027:

• LTSS Comprehensive Assessment and Update (LTSS-CAU).
• LTSS Comprehensive Care Plan and Update (LTSS-CPU).
• LTSS Shared Care Plan with Primary Care Practitioner (LTSS-SCP).
• LTSS Reassessment/Care Plan Update After Inpatient Discharge (LTSS-RAC).

NCQA does not propose to rate or compare organizations based on their performance on the measures at this time.

Utilization Management Accreditation

NCQA’s UM standards align across three programs—UM Accreditation, Health Plan Accreditation and MBHO Accreditation—especially related to delegation of UM functions.

NCQA will organize UM Accreditation standards into two categories: core requirements that apply to any entity pursuing UM Accreditation, and distinct evaluation options that allow organizations to select the types of UM services they offer.

MBHO Accreditation

Rising demand for—and lack of access to—effective behavioral health services is a significant challenge for patients and clinicians. In response to this crisis, NCQA proposes updates to MBHO Accreditation to better define how organizations create accessible and available networks that meet the needs of organization members and to measure the quality of care and services provided.

NCQA proposes to update the program name from “Managed Behavioral Healthcare Organization Accreditation” to “Behavioral Health Accreditation,” and update the standard categories to more closely align with Health Plan Accreditation, as follows:

• Create a separate category for Network Adequacy.
• Integrate Care Coordination into Quality Improvement and Management.
• Create a Population Health Management category.
• Rename “Members’ Rights and Responsibilities” to “Member Experience.”

Patient-Centered Medical Home Recognition

This program recognizes primary care practices that focus on improved communication and coordination in the medical neighborhood. NCQA proposes the following modifications for the 2026 year:

• Add 9 new elective criteria centered on virtual care.
• Retire 9 criteria that no longer drive significant improvement.
• Add 46 cadence thresholds to ensure that transformation is incorporated into the practice model, rather than as a one-time expectation.
• Implement a corrective action process to give practices the opportunity to rectify deficiencies without losing Recognition status.
• Align with Health Plan Accreditation to better facilitate payer-provider collaboration.

AI Evaluation

AI is widely adopted in the health care industry. Many frameworks provide guidance on its safe and ethical use, and NCQA intends to develop actionable standards that build on these. There is a gap in measuring and evaluating how organizations apply AI principles and demonstrate that their use of AI is effective and is monitored with a focus on quality improvement, outcomes and patient safety.

NCQA is presenting a set of AI questions in the following domains:

• Auditing/Monitoring/Validation.
• Error Handling/Incident Management in Production.
• Mitigating Bias.
• Transparency.

Public feedback will inform next steps in integrating AI expectations into NCQA’s programs, where applicable.

How to Participate in Public Comment

The public comment period ends at 5:00 p.m. (ET) on Tuesday, March 25. Visit My NCQA to submit comments. For details on proposed changes, visit the NCQA website.