FAQ Directory

Your overall rating will be “Partial Data Reported” and your measures will display as “NC” (No Credit) on the September 15 release of HPR on the NCQA Health Plan Report Card.

This applies to the following Programs and Years:

HPR uses the prior year Medicare CAHPS data so NCQA will use the corresponding Sub ID, therefore, could differ from the Medicare plan's CAHPS Sub ID of the HPR release year. 
 

This applies to the following Programs and Years:

Using Medicare CAHPS and HOS data in HPR depends on yearly approval by the Centers for Medicare & Medicaid Services (CMS). Because the submission schedule for Medicare CAHPS and HOS measures differs from the HEDIS submission schedule, NCQA scores organizations using the previous year’s data and percentiles for measures in the CAHPS and HOS domain.

There are also calculation differences between NCQA’s Medicare CAHPS and CMS. For example, NCQA scores some items based on a two-question composite where CMS uses a three-question composite. CMS case-mixes CAHPS results, NCQA does not. NCQA uses top-box scoring for HPR, CMS uses linear mean scoring converted from a 0-100 scale.

This applies to the following Programs and Years:

NCQA's Health Plan Ratings will be publicly displayed on or around September 15 on NCQA's Health Plan Report Card.

This applies to the following Programs and Years:

Please visit NCQA’s Health Plan Ratings website and select the applicable year to view our Advertising and Publicity Guidelines. Please note that this document is updated annually, no later than early September. 

This applies to the following Programs and Years:

Your CAHPS Component selection was made in the HOQ, which closed in February and was confirmed during Plan Confirmation in May. It is final and cannot be modified.

This applies to the following Programs and Years:

No. QI 2, Element C does not require bidirectional data sharing.

The intent of the requirement is for health plans to share data required for at least one HEDIS measure identified in QI 2, Element C. This enables behavioral health organizations to collect HEDIS measure data to meet NCQA’s Behavioral Health Accreditation program requirements. The health plan and the behavioral health entity collaboratively select the specific HEDIS measure(s), review the technical specifications outlined in Volume 2, and determine which data elements need to be shared to support accurate and efficient reporting.  

This applies to the following Programs and Years:

Members with an unknown or nonbinary gender do not qualify for the risk adjusted utilization measures (PCR, HFS, HFC, HFG, HFO, HFU, AHU, EDU, HPC, EDH) because these measures require a gender to assign age/gender weights. These members should be removed from the measures.

This is not a change; measure models have always included male and female weights. The use of the administrative gender codes for MY 2026 clarify which members are included in the initial population.

This applies to the following Programs and Years:

No. Each inpatient hospital stay does not need to be both acute and observation for direct transfer. When assessing for direct transfer, include those with acute inpatient to acute inpatient, observation to observation, acute inpatient to observation and observation to acute inpatient.

This applies to both MY 2026 and MY 2025

This applies to the following Programs and Years:

Yes. The HEDIS MY 2026 Technical Update will remove HCPCS G0136 from the measure’s screening numerators and remove ICD-10 Z codes from the measure’s intervention denominators. The measure will continue to rely on LOINC codes for documentation of standard screenings and positive screening results. Additionally, NCQA will update some intervention procedure value sets to align with current code lists.

This applies to the following Programs and Years:

NCQA updated the look-back period on the Medi-Cal Rx Crosswalk for UM 11, Element E to be “prior to the survey date” for the 2025 standards year. This applies to California Medicaid organizations only. 

The look-back period should read:

For Interim Surveys: Prior to the survey date for all Elements.
For First Surveys: 6 months for Elements A-D; prior to the survey date for Element E.
For Renewal Surveys: 12 months for Elements A and C; at least once during the prior year for Elements B and D; prior to the survey date for Element E.

This applies to the following Programs and Years:

No. Organizations must use the exact calculated average to determine the element score. Rounding is not allowed.

For example, a calculated average of 2.8 does not meet the required threshold of 3.0, and the element is scored “Partially Met.”

This applies to the following Programs and Years: