FAQ Directory: Long-Term Services and Supports Distinction for Health Plans

Yes. For the 2026 standard year only (surveys conducted between July 1, 2026, and June 30, 2027), NCQA will allow organizations to submit a detailed implementation plan.

The plan must include: 

• A description of actions to make UM criteria available electronically at the point of care.
• A timeline for implementation on or before June 30, 2027.

Look-Back Period: Effective immediately, the look-back period for the entire Element B for First Surveys and Renewal Surveys has changed from six months to “prior to the survey date.” 

This approach provides flexibility and additional time for organizations to meet requirements.

Applicable Standards:

• Health Plan Accreditation: UM 2, Element B.
• Behavioral Health Accreditation: UM 2, Element B.
• UM Accreditation: UM 4, Element B.

This applies to the following Programs and Years:

Yes. Data from UM delegates must be included in the UM denial and appeal rates reported for UM 1, Elements B-E (in Health Plan Accreditation). The intent of reporting the rates for these elements is to provide a comprehensive view of the organization’s UM denial and appeal rates. Therefore, the expectation is that the organization presents all rates in a single workbook, rather than separating requests received by the organization (e.g., health plan) and those received by the delegate.

Applicable standards:

• Health Plan Accreditation: UM 1, Elements B-E. 
• Behavioral Health Accreditation: UM 1, Elements B-D.
• Utilization Management Accreditation: UM 3, Elements B-E.

This applies to the following Programs and Years:

Yes. The statement in Element D clarifies that the system must document the date when the case manager completes each component of the initial assessment.   

• If all components are completed at one time, one date is sufficient.
• If components are completed at different times, the system must automatically capture the date associated with each factor in Element D. In this scenario, the organization will be scored down for any factor that does not have an automated date.

Applicable standards:

• Health Plan Accreditation: PHM 5, Element D

This applies to the following Programs and Years:

No. QI 2, Element C does not require bidirectional data sharing.

The intent of the requirement is for health plans to share data required for at least one HEDIS measure identified in QI 2, Element C. This enables behavioral health organizations to collect HEDIS measure data to meet NCQA’s Behavioral Health Accreditation program requirements. The health plan and the behavioral health entity collaboratively select the specific HEDIS measure(s), review the technical specifications outlined in Volume 2, and determine which data elements need to be shared to support accurate and efficient reporting.  

This applies to the following Programs and Years:

NCQA updated the look-back period on the Medi-Cal Rx Crosswalk for UM 11, Element E to be “prior to the survey date” for the 2025 standards year. This applies to California Medicaid organizations only. 

The look-back period should read:

For Interim Surveys: Prior to the survey date for all Elements.
For First Surveys: 6 months for Elements A-D; prior to the survey date for Element E.
For Renewal Surveys: 12 months for Elements A and C; at least once during the prior year for Elements B and D; prior to the survey date for Element E.

This applies to the following Programs and Years:

No. Organizations must use the exact calculated average to determine the element score. Rounding is not allowed.

For example, a calculated average of 2.8 does not meet the required threshold of 3.0, and the element is scored “Partially Met.”

This applies to the following Programs and Years:

No. Effective immediately for delegation oversight standards, organizations receive automatic credit for the delegation agreement semiannual reporting requirement in Element A, and for the delegation oversight semiannual report evaluation in Element C, when an NCQA-Accredited/Certified delegate performs an NCQA-required activity.  

For example, in Health Plan Accreditation, NET 6, Element A, factor 3 and NET 6, Element C, factor 3 receive automatic credit for an NCQA-Accredited/Certified delegate. 

This applies to all products. 

Note: This updated FAQ replaces the original version published on September 15, 2025. 

This applies to the following Programs and Years:

No. Effective immediately, NCQA changed its policy regarding Medicaid sanctions and exclusions. The State Medicaid agency is no longer a required source; it is now considered an optional source. 

For Medicaid sanctions, organizations may use any of the following sources: 

• State Medicaid agency. 
• AMA Physician Master File. 
• Federation of State Medical Boards (FSMB). 
• National Practitioner Data Bank (NPDB). 
• SAM.gov. 

For Medicaid exclusions, organizations may use any of the following sources: 

• State Medicaid agency. 
• List of Excluded Individuals and Entities (LEIE) maintained by the Office of Inspector General (OIG). 
• National Practitioner Data Bank (NPDB). 

Note: A related question was posted on July 15, 2025: “Obtaining Sanction and Exclusion information from the State Agency“. This FAQ replaces that post. 

This applies to the following Programs and Years:

The July 1, 2025, date is incorrect. For the 2026 standards and guidelines, factor 7 is scored NA for appeal notifications issued before July 1, 2026.  

This applies to the following Programs and Years:

In response to customer feedback, we are retracting the Policy Update issued on July 28, 2025.

Organizations must review sanctions, exclusions, limitations and expiration information at least monthly (once per month), or within 30 calendar days of receiving a new alert, if subscribed to a monitoring service. For example, an organization might conduct a review on September 1, and conduct another on October 15, 2026.

This update applies to applicable products for both the 2025 and 2026 standard years. NCQA will accept processes that follow a monthly schedule or a 30-day interval. 

We appreciate your ongoing feedback and support.

Applicable Standards:
HPA: CR 5, Element A, factors 1-3.
MBHO: CR 5, Element A, factors 1-3.
CRPN: CRA 5, Element A, factor 3; CRC 12, Element C, factors 1-3.

This applies to the following Programs and Years:

Under the 2025 standards and beyond, organizations must monitor adverse events for all practitioners. Limiting monitoring to primary care practitioners and high-volume behavioral healthcare practitioners is no longer acceptable.

This is a change from the 2024 standards.

Applicable Standards:
HPA: CR 5, Element A, factor 5.
MBHO: CR 5, Element A, factor 5.
CRPN: CRA 5, Element A, factor 5.

This applies to the following Programs and Years:

Yes, multiple goals can be assigned the same priority level (e.g., “high”), but the organization must still clarify the relative importance of each goal within the same assigned level. The intent of prioritization is to show how goals compare to one another in terms of urgency or importance.

For example, if three goals are all marked “high,” the organization must indicate which of those is the highest priority, second highest, and so on.

Update Notice:
This FAQ is being updated to clarify implementation expectations.
Organizations will have 90 days to implement the guidance outlined in this FAQ.
This means that organizations must adhere to the updated FAQ for surveys conducted on or after January 1, 2026.
Prior to January 1, 2026, organizations may continue to prioritize goals and reporting frequencies as they have in the past.

Applicable Standards:

HPA: PHM 5, Element E
MBHO: QI 8, Element I
CM: CM 4, Element B
CM-LTSS: LTSS 3, Element C

This applies to the following Programs and Years: