3,262
Additional women tested or treated
7.1 per 100 eligible
7.1 per 100 eligible
The Accreditation Advantage
How NCQA Health Plan Accreditation Supports Clinical Quality and CMS Star Ratings Performance
› EXECUTIVE SUMMARY
NCQA Accredited Medicare Advantage plans outperform non-Accredited plans.
NCQA Accredited Medicare Advantage (MA) plans outperform non-Accredited plans on clinical quality and achieve higher CMS Star Ratings, with a greater share of plans operating at 4- and 5-Star levels.
These findings are particularly relevant in a market defined by increasing financial pressure, regulatory scrutiny and competition for members. Star Ratings directly influence bonus payments, benefit design and market positioning, making quality performance a strategic priority.
NCQA Health Plan Accreditation provides a structured, repeatable framework that can help plans strengthen performance and improve their ability to compete.
What We Found
- Higher Star Ratings: Higher percentage of Accredited plans operate at 4- and 5-Star levels.
- Stronger HEDIS® performance: Accredited plans lead on core clinical quality measures across years.
- Better cut point performance: Accredited plans more often clear CMS thresholds tied to higher ratings.
- Modestly stronger CAHPS® results: Accredited plans trend higher on several member experience measures.
Why It Matters
- Performance drives revenue: Stronger results support bonus payments that plans can reinvest into enhanced benefits and services.
- Quality drives growth: High-performing plans are better positioned to compete for members.
- Accreditation supports repeatability: Accreditation helps plans build durable quality improvement capabilities.
AT-A-GLANCE
66%vs.52%
Accredited plans achieve 4-5 Stars 66% of the time,
vs. 52% for non-Accredited plans
vs. 52% for non-Accredited plans
Medicare Advantage lags other lines of business in plan accreditation.
Across Medicaid, Commercial and Exchange markets, NCQA Health Plan Accreditation has become the standard for demonstrating quality. In Medicare Advantage — the line of business with the highest financial stakes through Star Ratings and bonus payments — fewer than 4 in 10 plans are Accredited. This report examines what that gap costs.
WHY ACCREDITATION HAS GROWN
In Medicaid, Commercial and Exchange markets, plans have increasingly turned to Accreditation as a way to differentiate, demonstrate operational discipline and meet purchaser expectations. Medicare Advantage has historically had less external pressure to accredit.
WHAT CLOSING THE GAP COULD MEAN
652K
additional people receiving recommended care annually
Aggregated from real-world impact estimates across the three featured measures (Colorectal Screening, Blood Pressure Control, Glycemic Assessment). Replace with finalized methodology figures.
› KEY FINDING #1: STAR RATINGS
Accredited plans consistently achieve higher overall Star Ratings year over year.
Accreditation is associated with stronger outcomes and it provides the structure and discipline required to sustain quality improvement over time. NCQA has set quality standards for health plans for more than 35 years and our Health Plan Accreditation is widely recognized as a rigorous framework for quality improvement and operational excellence.
Accredited Plans More Often Score at 4-5 Stars
% of MA plans with an overall CMS Star Rating of 4 Stars or higher (MY 2022–2024)
AT-A-GLANCE
14%
More Accredited plans received an overall rating of 4-5 stars in MY 2024
› KEY FINDING #2: HEDIS PERFORMANCE
Accredited plans outperform non-Accredited plans across 12 HEDIS measures that are included in the Star Ratings formula.
The advantage observed among Accredited plans suggests that Accreditation is associated with the development of these capabilities in a systematic and repeatable way.
Accredited Plans Outperform Non-Accredited Plans Across 12 of 13 HEDIS Measures
Average performance rates (%), MY 2024
AT-A-GLANCE
+4PTS
Average performance advantage of accredited plans across the 13 HEDIS measures.
› KEY FINDING #3: CUT POINT PERFORMANCE
Accredited plans clear the 4-Star threshold more often—and the gap is widening.
CMS sets performance thresholds (cut points) that determine whether a plan earns 1 to 5 Stars on each measure. The 4-Star cut point is especially important because plans must earn a rating of 4 Stars or higher to qualify for bonus payments. Even small differences near the 4-Star cut point can swing rating outcomes—and bonus payment eligibility.
Accredited plans have widened their advantage over non-Accredited plans from +4 measures exceeding the 4-Star cut point in MY 2022 to +7 measures in MY 2024.
NUMBER OF MEASURES WHERE ACCREDITED PLANS EXCEED THE 4-STAR CUT POINT
MY 2022
7
Accredited
vs
3
Non-Accredited
+4
Measures
The gap between Accredited and non-Accredited plan performance.
MY 2023
6
Accredited
vs
1
Non-Accredited
+5
Measures
The gap widened by 1 measure from MY 2022 to MY 2023.
MY 2024
9
Accredited
vs
2
Non-Accredited
+7
Measures
Accredited plans demonstrated the strongest performance in MY 2024.
› KEY FINDING #4: CAHPS PERFORMANCE
Accredited plans perform better on CAHPS measures of patient experience.
Similar to the HEDIS measures, most CAHPS measures show that Accredited plans trend toward better performance, but with greater variability and smaller differences.
Accredited Plans Perform Better Than Non-Accredited Plans on Most CAHPS MeasuresPerformance gap in percentage points, MY 2024
| CAHPS Measure | Accredited Avg | Non-Accredited Avg | Performance Gap (percentage points) |
|---|---|---|---|
| Flu Vaccine | 69.23% | 65.75% | +3.48 |
| Health Plan Rating | 87.54% | 86.72% | +0.82 |
| Health Care Quality | 87.18% | 86.63% | +0.55 |
| Customer Service | 90.53% | 90.23% | +0.30 |
| Getting Care | 81.49% | 81.25% | +0.24 |
| Getting Appointments | 83.88% | 83.83% | +0.05 |
| Care Coordination | 87.24% | 87.28% | -0.04 |
Notes: 1. Gap = Accredited plan average minus non-Accredited plan average (percentage points). Positive values indicate Accredited plans score higher. 2. Analysis includes 661 unique plans in MY 2024.
CAHPS measures add aMEMBER EXPERIENCE LENSto plan performance
Accredited plans generallyTREND HIGHERon measures of access, quality and communication
Why this measure matters.
Select a measure to see why it matters and its real-world impact. Each spotlight opens as a two-page card.
› HEDIS MEASURE SPOTLIGHT
Osteoporosis Management in Women Who Had a Fracture
Why this measure matters
- Osteoporosis-related fractures can have serious consequences for health and independence.
- Women who experience a fragility fracture are more likely to experience another fracture.
- Bone density testing and prescription medications can help prevent future fractures.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
34–65
Fractures prevented in older women
$1M–$3M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Glycemic Status Assessment for Patients with Diabetes
Why this measure matters
- Poorly managed diabetes raises the risk of serious complications, including kidney disease, vision loss and cardiovascular events.
- Regular glycemic status assessment is essential to guide treatment and keep glucose levels in a safe range.
- The Glycemic Status Assessment for Patients With Diabetes (GSD) measure tracks whether members' glucose control was assessed and within range.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
144K
Additional people with controlled blood sugar
5.7 per 100 eligible
5.7 per 100 eligible
808–2,295
Diabetes-related deaths prevented
$21M–$46M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Eye Exam for Patients With Diabetes
Why this measure matters
- Left unmanaged, diabetes can lead to vision loss and blindness.
- Regular eye exams are the best way to reduce the risk of blindness and maintain a healthy and productive life.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
149K
Additional people screened
5.9 per 100 eligible
5.9 per 100 eligible
149–804
Vision loss cases prevented
$3M–$18M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Kidney Health Evaluation for Patients With Diabetes
Why this measure matters
- Diabetes is the leading cause of kidney disease.
- Undiagnosed chronic kidney disease can increase the chances of heart disease, stroke, kidney failure and end-stage renal disease.
- Kidney health testing can help people with diabetes understand and take action to lower their risk.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
197K
Additional people screened
5.9 per 100 eligible
5.9 per 100 eligible
197–983
Years of dialysis prevented
$9M–$47M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Colorectal Cancer Screening
Why this measure matters
- Colorectal cancer is the second leading cause of cancer-related death in the United States.
- Screening can identify precancerous polyps before cancer develops.
- Early detection drives much better survival outcomes.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
328K
Additional people screened
5.7 per 100 eligible
5.7 per 100 eligible
295–656
Cancers prevented, plus 134–524 cases caught earlier
$39M–$140M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Breast Cancer Screening
Why this measure matters
- Breast cancer is the second most common type of cancer among women in the U.S.
- Mammograms are the best method to detect breast cancer early—when it is easier to treat.
- Early detection can provide people with a greater range of treatment options, such as less aggressive surgery and less toxic chemotherapy.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
128K
Additional people screened
5.1 per 100 eligible
5.1 per 100 eligible
51–154
Cancers detected in earlier stages
$4M–$13M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Transitions of Care
Why this measure matters
- The Medicare population includes older adults and individuals with complex health needs who often experience fragmented care.
- High quality care transitions can lower the risk of readmissions, adverse events and drug-related errors, and improve patient satisfaction.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
156K
Additional people with coordinated care transitions
5.8 per 100 eligible
5.8 per 100 eligible
1,641–4,690
Readmissions prevented
Costs averted are included in the Plan All-Cause Readmissions measure.
› HEDIS MEASURE SPOTLIGHT
Controlling High Blood Pressure
Why this measure matters
- High blood pressure is a leading contributor to heart disease and stroke, among the top causes of death in the United States.
- Consistent blood pressure control substantially lowers the risk of heart attack, stroke and kidney damage.
- The Controlling High Blood Pressure (CBP) measure tracks the share of members whose blood pressure was adequately controlled.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
186K
Additional people with controlled blood pressure
3.4 per 100 eligible
3.4 per 100 eligible
780–1,801
Heart failure events and strokes prevented
$17M–$48M
Annual Medicare costs averted
› HEDIS MEASURE SPOTLIGHT
Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions
Why this measure matters
- Individuals with multiple high-risk chronic conditions are more likely to experience fragmented care and adverse healthcare outcomes.
- They often face communication lapses between the emergency department and outpatient care teams.
- Timely follow up after an emergency department visit can reduce the risk of medication errors, hospitalization and other adverse events.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
33K
Additional people with timely follow-up after an ED visit
1.7 per 100 eligible
1.7 per 100 eligible
82–655
Emergency department revisits and admissions prevented
Costs averted are included in the Plan All-Cause Readmissions measure.
› HEDIS MEASURE SPOTLIGHT
Statin Therapy for Patients With Cardiovascular Disease
Why this measure matters
- Cardiovascular disease is the leading cause of death in the U.S.
- Statin therapy can lower blood cholesterol and reduce the risk of major cardiovascular events.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
7,987
Additional people receiving statin therapy
1.2 per 100 eligible
1.2 per 100 eligible
80–112
Recurrent cardiovascular events prevented
Costs averted are included in the Controlling High Blood Pressure measure.
› HEDIS MEASURE SPOTLIGHT
Plan All-Cause Readmissions
Why this measure matters
- Readmission to the hospital within 30 days of discharge is frequently avoidable and can lead to adverse outcomes for patients.
- Initiatives to improve communication with patients and their caregivers, coordinate care after discharge and improve the quality of care during the initial admission can avert many readmissions.
REAL-WORLD IMPACT
If non-Accredited plans performed at the same level as Accredited plans, it could mean:
5,254
Additional patients receiving appropriate care after discharge
0.3 per 100 eligible
0.3 per 100 eligible
5,254
Readmissions prevented
$102M–$112M
Annual Medicare costs averted
Success Stories
SERVICE AREA
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Pennsylvania
MEDICARE MEMBERS
85,000
IN MEDICARE MARKET SINCE
2006
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Michigan
MEDICARE MEMBERS
270K
IN MEDICARE MARKET SINCE
2005
MY 2024 STAR RATING FOR COLORECTAL CANCER SCREENING:
5 Stars
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Meeting Members Where They Are: Geisinger’s Whole-Person Approach to Population Health and Quality Improvement
For Geisinger Health Plan (GHP), improving quality starts with a simple but powerful philosophy: care for the whole person, not just a diagnosis. That means addressing clinical needs alongside behavioral health, social determinants of health and barriers to care. GHP is part of Geisinger, an integrated health care delivery organization that serves communities across Pennsylvania. Its goal is to make healthcare easier and more accessible.
GHP demonstrates how NCQA Accreditation can serve as an engine for quality improvement. By providing a structured framework for population health management, performance measurement and organizational accountability, Accreditation helps transform quality initiatives into measurable gains in HEDIS performance, Medicare Star Ratings and member outcomes.
“Accreditation provides a framework for how to operate as a health plan. If you follow these steps in this order, you’ll be successful.”
Erin Griffith, Director, Quality Management, Geisinger Health Plan
Making Strategic Investments in Population Health
GHP’s population health approach extends well beyond traditional case management. It requires an understanding of the needs of the entire population. The plan has invested in programs that bring care directly to members, address social needs and provide highly specialized care for members with complex needs.
- Delivering home-based services. As part of its philosophy of meeting members where they are, GHP offers home-based programs like case management and nurse practitioner services—not just for members who are homebound, but for members who prefer to receive care that way. The plan also promotes virtual behavioral health services to provide more timely access and align with member preferences.
- Addressing social needs for all members. Historically, social needs assessments were primarily focused on members in case management, but GHP recently launched a social needs hub for its entire membership. The program connects members with specialized support for challenges such as food insecurity, transportation issues, housing instability and social isolation. Certified community health workers and behavioral health specialists work together to connect members with resources and close care gaps before they become larger health concerns.
- Investing in the right vendor partners. GHP recognizes that it can’t be everything to everyone. That’s why it invests in strategic partnerships with organizations that specialize in managing complex conditions such as kidney disease and cancer. These partnerships supplement GHP’s internal expertise while helping members access specialized support, education and care coordination. At the same time, GHP learns from these partners and integrates successful approaches into its operations.
- Looking beyond the data. Data serves as the foundation for GHP’s population health strategy. The plan relies on robust data sources to identify member needs, uncover gaps in care and prioritize interventions. But data alone is not enough. GHP’s population health strategies also account for individual circumstances and social factors that may not always appear in claims or clinical data.
Results
GHP exceeded the CMS 4-Star cut point for seven HEDIS measures included in the CMS Star Ratings in MY 2024 for its HMO plan and eight measures for its PPO plan.
“Our Star Ratings reflect thousands of daily actions focused on keeping people healthy and engaging them in their care. It’s about the care we wrap around our members, how we use data to drive our decisions and how we try to personalize care as much as we can.”
Eileen Evert, Senior Director, Quality and Accreditation, Geisinger Health Plan
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Closing Every Gap, One Member at a Time
Priority Health developed a “Next Best Action” process to guide member outreach. The approach identifies the next action required to close a care gap for each member. Outreach generally follows a stepped escalation model:
- Initial letter or email prompting a primary care visit and outlining needed services.
- More frequent outreach after six months if care has not been completed.
- A phone call from the care team to help schedule an appointment or address other barriers to care.
- Home screening kits mailed to members who still do not complete needed screening.
The program relies on a continuous flow of claims and chart review data to target members most in need of support. Priority Health’s leadership attributes improved colorectal screening performance to this structured, data-enabled, multi-channel approach.
› IMPLICATIONS
How these findings relate to the broader healthcare industry and what to do next.
These findings point to specific actions for plans and policymakers who want to close performance gaps, reduce financial risk and improve outcomes.
FOR MEDICARE ADVANTAGE PLANS
Accreditation and Star Ratings work together
Plans that pursue Accreditation are building the exact infrastructure that drives Star Ratings results. These investments compound and do not compete.
Focus on clinical quality as the primary driver of Star Ratings performance
Strong execution on HEDIS measures is a consistent and controllable lever for improving overall performance.
Prioritize performance at critical thresholds
Small improvements near CMS thresholds (cut points) can meaningfully influence Star Ratings outcomes, making targeted interventions particularly impactful.
Invest in repeatable quality improvement capabilities
Plans that embed structured processes for identifying care gaps, engaging providers and tracking performance are better positioned to sustain results over time.
FOR POLICYMAKERS & CMS STAKEHOLDERS
Accreditation aligns with value-based care priorities
Accreditation reinforces performance on measures directly tied to outcomes, supporting broader efforts to improve quality and accountability.
Performance gaps have real public health consequences
The difference between Accredited and non-Accredited plans translates into hundreds of thousands of missed screenings and thousands of preventable deaths per year.
Standardization of quality improvement practices promotes consistency
Accreditation provides a consistent framework, helping reduce variability in how plans approach quality improvement.
Independent validation strengthens plan oversight
Accreditation provides an evidence-based signal of a plan's ability to execute on quality measures over time.
