FAQ Directory

This applies to the following Programs and Years:

NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.

This applies to the following Programs and Years:

NCQA includes external entities that store, create, modify or use UM data for any function covered by the UM standards on behalf of the organization in the scope of Elements A and B, factor 6, with the exception of organizations whose only UM service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use UM data.
 

This applies to the following Programs and Years:

NCQA includes external entities that store, create, modify or use CR data for any function covered by the CR standards on behalf of the organization in the scope of Element C, factor 4, with the exception of organizations whose only CR service provided for  the organization is to provide cloud-based data storage functions and not services that create, modify or use CR data.
 

This applies to the following Programs and Years:

For elements that are reviewed and scored by product line, NCQA expects to see evidence or documentation for each product line. Each product line is scored separately.

For reports, it is acceptable to have one document if the data or analysis for each product line is clearly separated within the document. If a single documented process or policy and procedure applies to multiple product lines, the documented process must state the product lines to which it applies. For materials, if a single document applies to more than one product line, the organization must demonstrate this.
For elements that are not designated to be reviewed and scored by product line, NCQA reviews one document for the element if the product lines are managed the same. Documentation must demonstrate that it applies to all product lines included in the survey (e.g., data and analysis may be combined for a report, but it must be clear that they represent all included product lines).

Evidence in documentation does not need to be separated by product lines; all product lines receive the same score. However, if product lines are managed differently, the element is treated as if it was designated to be reviewed and scored by product line, as described above.

This applies to the following Programs and Years:

Yes. Distributing the rights and responsibilities statement to all members and practitioners (new upon enrollment and annually to existing) is acceptable, because it is consistent with prior years' and exceeds the standards effective July 1, 2020. Factors 2 and 4 will be scored yes; organizations are not required to track requests for existing members and practitioners during the look-back period.

This applies to the following Programs and Years:

No. The look-back period should be specified as 12 months for all product lines, for Renewal Surveys, which is consistent with the other file review standards and elements. NCQA initially changed the scope of review to account for a change made to verbal notification and how it no longer affords organizations an extension.

However, because of this error, if an organization does not meet a factor in UM 5, Elements A-C within the first 6 months of the look-back period, NCQA does not penalize the organization and scores the file “NA” instead of “Not Met” for Medicaid surveys.

This applies to the following Programs and Years:

Yes. Due to changes in reporting requirements because of COVID-19, organizations that do not report HEDIS 2020 results this year may use their audited HEDIS 2019 (MY 2018) reportable hybrid rates when considering sample size reduction rules for HEDIS MY 2020 reporting. In addition, if an organization is required to report their MY2019 administrative rate for HEDIS 2020, they will still be able to use their audited HEDIS 2019 (MY 2018) reportable hybrid rates when considering sample size reduction.

This applies to the following Programs and Years:

Yes. The final reported hybrid rates for HEDIS 2020 (MY2019), regardless of rotation decision, can be used when applying sample size reduction rules for HEDIS MY2020 reporting.

This applies to the following Programs and Years:

Although HEDIS/CAHPS results collected in 2020 reflect Measurement Year (MY) 2019, COVID-19 is impacting key aspects of HEDIS hybrid data collection and consumer experience nationally in 2020. The NCQA ratings methodology includes HEDIS/CAHPS measures and Accreditation status. While HEDIS/CAHPS reporting remains a required component of commercial and Medicaid Accreditation, we will not calculate an overall Health Plan Rating for MY 2019, because key aspects of data collection—especially consumer experience/CAHPS survey data—are understood to be compromised by the 2020 pandemic.
In addition to Accreditation, there are two components of Health Plan Ratings to consider when determining comparability for performance assessment: HEDIS and CAHPS results.

1. HEDIS:
   1. Measures specified to use administrative data only: We expect HEDIS administrative measures to be less impacted; however, we are monitoring them closely. 
   2. Measures specified to use administrative data with a medical record review component (Hybrid Method): We expect some HEDIS hybrid measures to be compromised, given the challenge of accessing charts for abstraction.
2. CAHPS: We have concerns about the validity of CAHPS results because the survey is being fielded this year from February–May, during the height of the pandemic as it continues to spread unevenly across the country, with wide regional variation.

Considerations: Preliminary impact modeling using MY 2018 data has shown that approximately half of all plans’ overall ratings would be affected if Hybrid measures and/or CAHPS survey results were excluded from Health Plan Ratings. Given the uncertainty and likely variability of COVID-19’s impact on hybrid data collection efforts and consumer experience, NCQA will not calculate ratings for comparison of plans in 2020 for MY 2019. Ratings based on a reduced set of measures would not be comparable to previous Health Plan Ratings.

In addition, since NCQA will align with CMS guidance (https://www.federalregister.gov/documents/2020/04/06/2020-06990/medicare-and-medicaid-programs-policy-and-regulatory-revisions-in-response-to-the-covid-19-public), we will not require Medicare Advantage plans to submit data for Accreditation. In order to maintain alignment across all product lines, we want to recognize commercial and Medicaid plans for collecting and reporting data; however, we understand that some plans’ ability to submit HEDIS/CAHPS data might be compromised. We will work with these plans individually.

This applies to the following Programs and Years:

CAHPS: CAHPS survey results will not be included in Quality Compass. We have concerns about the validity of CAHPS results because the survey is being fielded this year from February–May during the height of the pandemic as it continues to spread unevenly across the country, with wide regional variation.   

HEDIS: We will continually assess the feasibility of using the data reported to us for other purposes, including Quality Compass, provided data meet our usual standards for validity, accuracy and completeness. No public reporting will be done on any measures failing to meet such criteria. 
 

This applies to the following Programs and Years:

NCQA’s Health Plan Accreditation program consists of three components that together uniquely evaluate a plan’s infrastructure, consistency, quality and compliance. In addition to structure and process standards, NCQA also requires plans to have a robust framework for gathering, reporting, analyzing and acting on member experience (CAHPS) data and health outcomes (HEDIS) measures.

Although compliance with our standards is reviewed every three years, HEDIS/CAHPS reporting is assessed annually. This assessment is two-fold: We evaluate reporting compliance and capabilities and we calculate performance outcomes for benchmarking with other plans. While we will not calculate a performance outcome by way of our Health Plan Ratings in 2020, we will still assess whether plans are maintaining their reporting and quality infrastructure.
 

This applies to the following Programs and Years: