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If an organization does not have evidence that, during the look-back period, it assisted members transition to care when their benefits were exhausted (QI 3, Element E), NCQA reviews the organization’s policies and procedures in place throughout the look-back period.
In addition to the policies and procedures, the organization must provide documentation (e.g., attestation) indicating that there were no such instances during the look-back period.
Yes. The following changes apply to SNP 2, Assessing and Coordinating Care.
NCQA added a new Element F, Contracts with Long-Term Care Institutions for I-SNP Members, that requires organizations to confirm that contracts with long-term care institutions for its I-SNP members, allow I-SNP clinical and care coordination staff access to I-SNP members who are institutionalized.
NCQA will review materials submitted by the organization that demonstrates that the organization’s contracts for I-SNP members allow I-SNP clinical and care coordination staff access to I-SNP Members who are institutionalized.
An institutionalized individual is defined in CFR § 422.2 as a special needs individual, and for the open enrollment period for institutionalized individuals at § 422.62(a)(4), an MA eligible individual who continuously resides or is expected to continuously reside for 90 days or longer in one of the following long-term care facility settings:
(1) Skilled nursing facility (SNF) as defined in section 1819 of the Act (Medicare).
(2) Nursing facility (NF) as defined in section 1919 of the Act (Medicaid).
(3) Intermediate care facility for individuals with intellectual and developmental disabilities as defined in section 1905(d) of the Act.
(4) Psychiatric hospital or unit as defined in section 1861(f) of the Act.
(5) Rehabilitation hospital or unit as defined in section 1886(d)(1)(B) of the Act.
(6) Long-term care hospital as defined in section 1886(d)(1)(B) of the Act.
(7) Hospital which has an agreement under section 1883 of the Act (a swing-bed hospital).
(8) Subject to CMS approval, a facility that is not listed in paragraphs (1) through (7) of this definition but meets both of the following:
(i) Furnishes similar long-term, healthcare services that are covered under Medicare Part A, Medicare Part B, or Medicaid; and
(ii) Whose residents have similar needs and healthcare status as residents of one or more facilities listed in paragraphs (1) through (7) of this definition.
This new element is NA for C-SNP and D-SNP members.
Applications processed before July 1, 2025, will not be held to the factor 6 requirement and will be scored NA.
Applications processed on or after July 1, 2025, will be scored on the factor 6 requirement, but will not be held against the 6-month look-back period until surveys on or after January 1, 2026.
Note: CAQH is updating its credentialing application to include fields for race, ethnicity and language, and a statement regarding anti-discrimination. Updates are scheduled to go live on July 1, 2025.
This applies to:
HPA: CR 3, Element C, factor 6.
CRPN: CRA 3, Element A, factor 6; CRC 10, Element A, factor 6; CRC 11, Element A, factor 6.
MBHO: CR 3, Element C, factor 6.
Yes. The intent of LTSS 2, Element B in CM-LTSS (HE 2, Element F in HEA; LTSS 1, Element E in HPA) is that organizations have policies and procedures in place for managing access to and use of race/ethnicity and language data that cover all forms of media, devices and data storage.
Yes. During the audit in CR 8, Element C in HPA/MBHO (CR 2, Element C in CRPN), organizations must review all credentialing information in Element A associated with the selected practitioners’ files. This includes all credentialing verification information, credentialing committee minutes and ongoing monitoring reports.
Non-file Review Annual Evaluation
If a survey submission date is on or after July 1, 2025, the organization is assessed against the 2025 Standards and Guidelines, and is expected to hold delegate(s) to 2025 requirements.
File Review Annual Audit
If a credentialing file audit (CR 9, Element C, factor 2 in HPA/MBHO; CR 3, Element C, factor 2 in CRPN) is scheduled to occur before July 1, 2025, the organization should continue the routine scheduled annual delegation audits for credentialing and recredentialing files, and audit the files against the 2024 credentialing verification time limits.
If a credentialing file audit is scheduled to occur on or after July 1, 2025, credentialing files processed by the organization’s delegate(s) before July 1, 2025, are assessed against 2024 verification time limits; files processed by the organization’s delegate(s) on or after July 1, 2025, are assessed against 2025 verification time limits.
For Health Plan, MBHO and Credentialing Accreditation, “processed” refers to the credentialing decision date.
For Credentialing Certification, “processed” refers to the date when credentialing verifications are reported to the client.
For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources. |
No. Verification of sanctions and exclusions are not product line–specific requirements. For each practitioner in the scope of credentialing, the organization must verify Medicare and Medicaid sanctions regardless of the product line for which practitioners are contracted.
