FAQ Directory: HEDIS

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4.20.2020 COVID-19 Why is NCQA requiring commercial and Medicaid Accredited plans to report HEDIS and CAHPS for Measurement Year 2019?

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.
 

HEDIS 2020

4.16.2020 COVID-19 If a hybrid measure has multiple indicators that were reported using both the hybrid and administrative option for HEDIS 2019 (MY 2018), how do I report it this year if I’ve decided to rotate the measure? For example, I reported CDC hybrid last year, except for eye exam, which I reported administratively.

NCQA requires hybrid measures with multiple indicators to be reported using the same measurement year of data. Because of this requirement, if you report all CDC indicators hybrid last year (except for eye exam, which you reported administratively):

  • Rotate all CDC indicators and report the hybrid data for all CDC indicators you reported hybrid, and
  • Report eye exams using the MY 2018 administrative data.  

This is the only exception for using prior years’ administrative data.
 

HEDIS 2020

3.26.2020 COVID-19 If organizations decide to report their audited HEDIS 2019 hybrid rate for one hybrid measure, are they required to do this for all hybrid measures?

No. Organizations may apply this exception (i.e., rotation of the audited HEDIS 2019 hybrid rate) to any or all hybrid measures as they deem necessary.

HEDIS 2020

3.26.2020 COVID-19 For measures where the data collection methodology can be decided at the indicator level (e.g., WCC, COA, CDC, TRC), may organizations choose to apply the exception (report audited HEDIS 2019 hybrid rate) to only one indicator?

No, because of limitations in IDSS organizations must report all indicators of a hybrid measure using the same year of data. For example, if the audited HEDIS 2019 hybrid data are being reported for CDC, then all indicators in CDC must be reported using audited HEDIS 2019 hybrid data. You may not just report audited HEDIS 2019 data for one indicator. This also applies to measures like WCC, COA, CDC and TRC.
 

HEDIS 2020

3.25.2020 COVID-19 What retrieval rate are auditors verifying against to have the rate considered low?

Auditors are not expected to validate a retrieval rate. There is no required retrieval rate that organizations have to meet in order to decide to stop their hybrid project this year.

HEDIS 2020

3.25.2020 COVID-19 If organizations choose to report their audited HEDIS 2019 hybrid rate, what data elements should they report in IDSS?

Organizations must report all IDSS data elements for any hybrid measure they report using their audited HEDIS 2019 hybrid rate.

HEDIS 2020

3.17.2020 COVID-19 Where do organizations note in IDSS that they are reporting their audited HEDIS 2019 hybrid rate?

Organizations cannot indicate that they are reporting their audited HEDIS 2019 hybrid rate in IDSS. Organizations must work with their auditors to ensure that these rates are reported correctly.

HEDIS 2020

3.17.2020 COVID-19 If organizations report a HEDIS 2020 measure using the Administrative Method, may they use their audited HEDIS 2019 rate instead?

No, measures being reported using the Administrative Method should be reported following the HEDIS 2020 reporting requirements. Only measures being reported using the Hybrid Methodology may report the higher of the HEDIS 2020 hybrid rate or the audited HEDIS 2019 hybrid rate.

HEDIS 2020

3.17.2020 COVID-19 May organizations enter data manually in IDSS, and will it trigger a warning?

Yes. Organizations may manually enter data in IDSS for HEDIS 2020; this will trigger a validation warning. Organizations should be able to explain to their auditor why the warning appeared.

HEDIS 2020

3.17.2020 COVID-19 Does NCQA have any guidance for MY 2020 reporting (June 15, 2021) and the impact COVID-19 will have on care delivery?

NCQA is actively working on a plan for MY 2020 reporting. We will announce our decisions as soon as they are finalized.

HEDIS 2020

3.16.2020 Plan All-Cause Readmissions When an index hospital stay is discharged to skilled nursing care facilities (SNF) which date is used for reporting the measure?

The discharge date from the index hospital stay should be used for reporting. The PCR measure assesses the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission. SNFs are considered to be nonacute inpatient settings. Therefore, when a member is transferred from an acute inpatient setting to a SNF, only the acute inpatient stay is assessed for reporting.

For example, a member has an acute inpatient stay February 1 – 5 and was discharged to a SNF February 6 – 9 and then transferred back to acute inpatient care February 10 – 14. There are two acute inpatient stays which are assessed for the PCR measure and count as two index hospital stays for the denominator (Stay 1 is February 1 – 5, Stay 2 is February 10 – 14), provided they meet all other measure criteria. Stay 2 is a readmission for Stay 1, provided it meets all numerator criteria because it occurs within 30 days of the discharge date for Stay 1. Stay 1 counts as an index hospital stay discharged to a SNF.
 

HEDIS 2020

3.16.2020 Plan All-Cause Readmissions Which risk weights are assigned to index hospital stays discharged to skilled nursing care when calculating expected readmission rates for the Medicare product line?

For the Medicare product line only, a “Skilled Nursing Care Stratification” was added to highlight the readmission rate among non-outlier Medicare beneficiaries who were discharged from the hospital to skilled nursing care. An index hospital stay discharged to skilled nursing care experienced by a non-outlier Medicare beneficiary is reported in several places and receives two sets of risk weights.

The tables in the PDF (https://www.ncqa.org/wp-content/uploads/2020/03/20200312_2020_PCR_Tables.pdf) illustrate assignment of risk weights for index hospital stays among two hypothetical Medicare beneficiaries meeting all other measure criteria (e.g. non-outlier, continuously enrolled, etc.). Index Hospital Stay #2 for member 1101 and Index Hospital Stays #1 and #2 for member 1202 are discharged to skilled nursing care.

Table 1 shows that these index stays are assigned the standard set of risk weights for reporting in Table PCR-A-1/2/3 and Table PCR-B-3. Do not assign the skilled nursing care risk weights for the stays in Table PCR-A-1/2/3 and Table PCR-B-3.

Table 2 shows that these same index stays are assigned the skilled nursing care risk weights for reporting the “Skilled Nursing Care Stratification” in Table PCR-C-3. Do not assign the standard set of risk weights for the stays in Table PCR-C-3.

Index hospital stays that are not discharged to skilled nursing do not need to be assigned the skilled nursing care risk weights and are not reported in the “Skilled Nursing Care Stratification” in Table PCR-C-3.  Index Hospital Stays #1 and #3 for member 1101 are examples of events that do not need to be assigned the skilled nursing care risk weights and are not reported in the “Skilled Nursing Care Stratification”. The “Skilled Nursing Care Stratification” applies to the Medicare product line only and index hospital stays among other product lines do not use the skilled nursing care risk weights.



 

HEDIS 2020