NCQA Responds to CMS RFI on Medicare Advantage Data

NCQA provides comments on the Medicare Advantage Data RFI in the following areas: care quality and outcomes; prior authorization and provider directories; and supplemental benefits.

May 29, 2024

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201

Attention: CMS-4207-NC

Dear Administrator Brooks-LaSure:

The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the CMS Request for Information on Medicare Advantage Data.

NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate their journey toward an equitable, digitally enabled health care system. Our mission to improve the quality of health for all Americans, with a focus on health equity and support for meaningful value-based payment models, propels our daily work.

We agree with CMS that increased data transparency and accountability will strengthen the Medicare Advantage program and enhance beneficiary access to care. This is important, since enrollment in Medicare Advantage now exceeds half of Medicare beneficiaries. The data challenges highlighted in CMS’s Request for Information on Medicare Advantage Data directly affect health care quality; timely and accurate data are needed to conduct meaningful quality improvement.

NCQA is pleased to provide comments in the following areas:

  • Care Quality and Outcomes. We encourage CMS to leverage accreditation in the Medicare Advantage market to enhance data collection and drive more equitable, transparent care for our nation’s seniors.
  • Prior Authorization and Provider Directories. NCQA urges CMS to ensure that advanced technology is used to drive more accurate, reliable plan networks, and to create more effective and less burdensome approaches to giving beneficiaries equitable access to the best care. We encourage CMS to establish and collect prior authorization measures across programs.
  • Supplemental Benefits. We support CMS’s interest in collecting supplemental benefit data. We suggest CMS develop quality measures on how supplemental benefits improve health outcomes.

Care Quality and Outcomes

We commend CMS’s commitment to improving quality and health outcomes, and to advancing health equity and whole-person care. Standardizing data collection across programs will allow CMS to track and enhance care coordination, access and availability of health resources and health equity. We encourage CMS to leverage accreditation in the Medicare Advantage market to drive more equitable, transparent care for our nation’s seniors.

Accreditation, an important accountability model, is used across CMS programs (e.g., in hospital and post-acute facilities). The Affordable Care Act required every Exchange Marketplace plan to be accredited, and most plans choose NCQA’s Health Plan Accreditation program. We are proud that more than 1,250 health plans have earned NCQA Accreditation, and 42 states use or require the program. NCQA Accreditation programs can support CMS’s goal of enhanced data collection and insights into quality improvement, utilization management, access and availability and consumer protections.

NCQA acknowledges and values CMS’s dedication to promoting digital quality measurement in support of safe, equitable care. This objective was articulated in CMS’s initial proposal for the Universal Foundation of Quality Measures, and we commend subsequent efforts to align quality measure programs across CMS using this foundation. NCQA developed and continues to refine a roadmap for converting all measure specifications in our programs to digital format over the next 5+ years. This transition will allow for faster, streamlined evaluation of how health plans manage population health, implement best practices and quality improvement processes, perform network and utilization management and facilitate member connections.

NCQA applauds CMS’s collaboration with ONC to promote interoperability and ensure standardized digital data elements for quality measures through U.S. Core Data for Interoperability (USCDI) and USCDI+. NCQA is aligned with these efforts to define essential data elements for nationwide, interoperable data exchange, and we look forward to supporting the evolution of the core and expanded datasets, such as for USCDI+ Quality. Last summer, NCQA provided feedback on ONC’s draft data element list for USCDI+ Quality. We intend to leverage USCDI in our digital initiatives, and we believe it is critical to keep USCDI datasets consistent and coordinated for broad adoption.

NCQA also provided feedback on the draft dataset for USCDI+ Behavioral Health. These data are critical to improving the quality of services, and for ensuring that services meet the needs of aging populations across the country. As more people with identified behavioral health challenges enroll in Medicare Advantage, there must be transparency into the quality of and access to supports for this population. Our recommendations aim to enrich the depth and breadth of digital datasets, and lay the groundwork for impending federal initiatives tailored to providing comprehensive, high-quality, high-value care.

CMS must continue to expand upon these initiatives to fully realize the potential of digital health data in facilitating dynamic, value-based care arrangements and addressing health disparities. Supporting endeavors such as the Digital Quality Implementers Community, and advancing the USCDI and USCDI+ programs, are important steps.

We are encouraged by CMS’s decision to leverage NCQA’s HEDIS Electronic Clinical Data Systems (HEDIS ECDS) reporting for Medicare Advantage Star Ratings. HEDIS ECDS reporting gives health plans a method for collecting and reporting structured electronic clinical data from a variety of sources, including clinical electronic health records. The ECDS architecture was designed to help HEDIS implementers leverage validated sources of clinical data beyond claims and electronic data, to improve the efficiency of quality reporting and to offer a path to a broader array of actionable information for care and reporting. The ECDS reporting method provides flexibility and lays the foundation for a shared goal of CMS and NCQA: all-digital quality measure reporting. We look forward to working with CMS to help the industry evolve to a more efficient measurement system that takes full advantage of digital technologies to improve care and quality outcomes.

Prior Authorization and Provider Directories

We applaud CMS for its recent strides in promoting interoperability and streamlining prior authorizations with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). However, we believe there is room to clarify requirements for prior authorization metrics. For example, relying on plans to publish these metrics on their websites introduces wide variability. We recommend CMS collect these data universally and establish industrywide metrics for better comparability and accountability. We welcome the opportunity to support CMS in developing FHIR-based specification and reporting requirements to support the metrics required in the latest rule.

We urge CMS to continue refining its efforts, with consideration of the increasing reliance on algorithms in utilization management. And, while we are enthusiastic about the potential of AI to enhance health plan operations and the consumer experience, we must also recognize the risks associated with poorly implemented AI, which can result in delayed or denied care that may increase disparities in care. NCQA is currently enhancing our utilization management standards to adapt to the evolving AI landscape, balancing the opportunities it presents with its potential threats to patient care.

NCQA commends CMS for further exploring the reliability and network design of Medicare Advantage plans. Provider directory accuracy and ghost networks remain a problem. We were encouraged by CMS’s continued support of HL7’s FAST National Healthcare Directory Implementation Guide and the API regulations for provider directories in the CMS-0057
final rule.

Supplemental Benefits

NCQA supports CMS’s recent proposals to enhance reporting of data on supplemental benefits. While these requirements are substantial, we believe they are necessary to evaluate whether supplemental benefits contribute to better health outcomes for Medicare Advantage beneficiaries overall. We encourage CMS to develop quality measures in this domain to gather more insights on supplemental benefits.

We appreciate CMS’s recent policies to help beneficiaries access supplemental benefits offered in plan design, and CMS’s interest in using the Social Needs Screening and Intervention measure in Medicare Advantage Stars. This measure assesses members who were screened for unmet food, housing and transportation needs, and received a corresponding intervention after a positive screen.

As social drivers of health interventions (e.g., food, housing support, transportation) become more common in supplemental benefit offerings, CMS can leverage accreditation programs to broaden the scope of current data collection and transparency requirements. Addressing unmet social needs improves patient health experiences and outcomes, and using standardized programs helps organizations collect data uniformly and reliably. We encourage CMS to require Health Equity Accreditation for Medicare Advantage plans to advance these goals.

Thank you for the opportunity to comment. We remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system. We welcome a discussion on our experience and recommendations to enhance data capabilities and improve Medicare Advantage data transparency. If you have any questions, please contact me at (202) 955-3590 or

Eric J. Musser
Vice President, Federal Affairs
National Committee for Quality Assurance

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