This year, almost a thousand commercial, Medicare Advantage (MA) and Medicaid health plans earned a 0–5 star rating from NCQA.

How Do Ratings Work?

Health plans are rated on a scale of 0–5 stars. NCQA considers plans with 4.5 and 5 stars as the highest-rated health plans in the nation. Ratings are based on three types of quality metrics:

• Measures of clinical quality from the Healthcare Effectiveness Data and Information Set (HEDIS^®) and the Health Outcomes Survey (HOS).
• Measures of patient experience using the Consumer Assessment of Healthcare Providers and Systems (CAHPS^®).
• Results from NCQA’s review of a health plan’s structure and quality processes (Health Plan Accreditation).

The overall rating is the weighted average of a plan’s HEDIS, CAHPS and HOS measure ratings, plus Accreditation bonus points, if the plan is NCQA-Accredited.

The 2026 Health Plan Ratings are based on Measurement Year (MY) 2025 data and percentiles for HEDIS and for commercial and Medicaid CAHPS. We use MY 2024 data and percentiles for Medicare CAHPS and HOS. Learn more about the Ratings methodology here.

What Is New for 2026 Ratings?

We added two measures, revised three measures to use the Electronic Clinical Data Systems (ECDS) reporting method and removed 12 measures from the 2026 Health Plan Ratings Measure List, located here.

Highlights and Results

This year, 18 plans earned a 5-star rating—an increase of 64% from last year—and 53 plans achieved a 4.5-star rating. NCQA observed positive trends in quality measures.

Behavioral Health Leads Performance Gains

Behavioral Health emerged as one of the highest-performing domains across product lines, reflecting increased investment in mental health access, care coordination and follow-up care. Follow-Up After Hospitalization for Mental Illness (FUH) was among the most improved measures, increasing by 8.9 percentage points in commercial, 9.0 points in Medicaid and 11.9 points in MA.

Chronic Disease Management Continues to Improve

Performance improved on nearly 80% of chronic disease management measures, with 22 of 28 indicators showing year-over-year gains. One standout trend from this year’s ratings was that MA plans saw significant improvement in Kidney Health Evaluation for Patients With Diabetes (KED), which increased by 7.3 percentage points. Although chronic care performance improved overall, declines in diabetic eye exam performance highlight an area for closer attention and stronger preventive care.

Quality Is Rising as Performance Gaps Narrow

Average benchmark performance increased across commercial, Medicaid and MA, with gains ranging from 1.6 to 1.8 percentage points. Medicaid saw the broadest improvement, with 89% of measures improving year over year. At the same time, variation between high- and low-performing plans decreased across all product lines, suggesting that improvements were widespread rather than limited to top-performing plans.

How Can You Use Ratings?

Ratings serve as a national benchmark for healthcare quality and outcomes, which can support broader quality improvement efforts.

Policymakers and Regulators

• States use NCQA Health Plan Ratings to evaluate and select health plans that provide high-quality care for Medicaid beneficiaries.
• Many states mandate NCQA Accreditation for Medicaid health plans, which requires plans to submit data for scoring in the ratings.
• Ratings can play a strategic role in helping states meet Medicaid and Children’s Health Insurance Program (CHIP) Quality Rating System goals and stay aligned with CMS Final Rule requirements.
• State and federal programs, including MA, use ratings performance data for value-based payment programs to reward plans that deliver superior care.
• Ratings are publicly available on NCQA’s Health Plan Report Card website for industry benchmarking and transparency, allowing states to compare plans and hold them accountable for performance.

 Health Plans

• Ratings help plans identify gaps in care and services and can serve as a roadmap for targeted quality improvement strategies.
• Ratings incentivize continuous improvement by highlighting areas of excellence and underperformance.

 Consumers and Employers

• Ratings help employers and consumers identify health plans that consistently deliver high-quality care and prioritize member experience.
• Consumers and employers can search for a health plan by name, filter health plans based on criteria (e.g., star rating, states served) and compare results across multiple plans for health topics such as diabetes, cancer screening or women’s reproductive health.

Learn More

View the 2026 Health Plan Ratings here.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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The pilot was structured in two phases. In phase one, we worked closely with participants to review and refine NCQA’s proposed standards through discussions and working sessions. In phase two, organizations applied the standards and submitted evidence to NCQA so we could assess the feasibility of the standards and requirements.

Thank You to Our Pilot Participants

NCQA selected four organizations through a competitive process based on their readiness and ability to lead change in primary care and their dedication to innovation and excellence. We appreciate the time and effort they dedicated to the pilot.

• Aledade, a national care enablement company supporting over 3,000 independent primary care practices.
• Bluegrass Community Health Center, a Federally Qualified Health Center serving 11,000 underserved Kentuckians.
• Jefferson Health, a 33-hospital, 700-site system serving patients in Pennsylvania.
• NYC Health + Hospitals, the nation’s largest public health system, serving over 1 million patients across 11 hospitals and 29 health centers.

“Our pilot participants showed us how all this work aligns with what matters to them and to their patients,” says Jeff Sitko, Assistant Vice President of Product Management at NCQA. “Their insights, along with feedback we received from public comment, helped us strengthen the model and ensure that it is both practical and scalable across a wide range of care delivery organizations.”

What We Learned

Here are the top insights from the pilot participants.

Focus on outcomes over process documentation. One participant stated: “Focusing on outcomes is the most important thing. If your outcomes are high, it most likely means that you have aligned policies and procedures to support those outcomes. If you focus on your outcomes, everything will fall into place.”

Patient-Centered Medical Home (PCMH) Recognition provides a strong foundation. A participant from a PCMH Recognized practice said: “Having the Patient-Centered Medical Home Recognition was helpful in that we were familiar with NCQA’s expectations of quality. A lot of the evidence and documented processes that we already had in place translated to the new program. It didn’t feel like it was adding a lot of unnecessary extra work to what we were already doing.”

Specific metrics drive broader system improvements. As one participant explained: “I think we can all agree that hypertension control matters. But individual metrics can also help to direct attention and resources toward building systems of care for patients who have chronic disease in general. The work we do as an organization to improve our hypertension control rates also teaches us about team-based care, registry development, patient engagement and how to think about equity.”

Robust data analytics capabilities are essential. Another participant focused on the value of analytics: “Our data analytics capabilities have grown tremendously over the years. This includes robust homegrown dashboards and key metrics for population health, access, utilization, care coordination and various health drivers including social determinants of health, insurance status, race and ethnicity. The dashboards allow our users to track, trend and act on data, which is critical to improving patient care.”

Early cross-functional collaboration is critical. According to one participant, collaboration is key: “Through this pilot, we learned that we have a lot of subject matter experts and we need to include them from the inception when we start to do things like this. That was one of the hurdles we had to climb in order to understand our systems and how they can work better.”

Accreditation helps payers identify true value-based care performers. A participant expressed the benefits of Accreditation for purchasers: “Some employers, particularly those who are self-insured, might hear all these buzzwords at industry conferences, but they don’t know how to find the right group of practices who are actually doing the work. I think that an Accreditation from NCQA will help those purchasers understand who can help them positively impact their total cost of care while improving quality.”

About NCQA’s Primary Care Advancement Program

This program defines and advances high-quality, coordinated primary care in today’s rapidly evolving environment. It is organized across six domains:

• Population Health Management.
• Coordinated Team-Based Care.
• Patient Safety and Experience.
• Behavioral Health.
• Clinical Quality.
• Data Management and Exchange.

“This program is intentionally designed to Accredit at the highest level of accountability, so instead of filling out an application for every individual site, organizations will be evaluated once and the results will apply across all sites,” says Sitko. “The goal is less paperwork and more time spent on care.”

Learn More

Listen to our webinar recording, Shaping the Future of Primary Care: Insights from the Advanced Primary Care Pilot, to learn more about the pilot program and what we learned.

Purchase the 2027 Primary Care Advancement Accreditation Survey Readiness Package in the NCQA Store.

The post NCQA’s Advanced Primary Care Pilot: What We Learned appeared first on NCQA.

This year’s Health Innovation Summit theme—Quality’s Next Chapter—reflects our commitment to advancing digital quality, modernizing measurement, reducing burden and embedding equity into everything we do—in partnership with clinicians, health plans, systems and communities.

The summit brings together healthcare quality leaders to focus on what matters most: better strategies, measurable results and partnerships that move quality forward.

Keynote Sessions at the Health Innovation Summit

Don’t miss this chance to hear from leading voices in healthcare quality.

Beyond the Scorecard: Real-Time, Patient-Centered Measurement That Clinicians Trust

Clinicians do not need more measures—they need better ones. This session explores how quality measurement can shift from compliance and burden to clarity, cohesion and trust. Expect a candid conversation about what to stop doing, what to simplify and what to build next.

Keynote Speakers

• Alice Chen, Centene Corporation
• Arjun Srinivasan, Joint Commission
• Caleb Stowell, Providence St. Joseph Health
• Susannah Bernheim, The John A Hartford Foundation

Fireside Chat with Seema Verma

Hear how interoperability and real-time data exchange are building a stronger quality ecosystem—and enabling future AI-powered tools to drive efficiency and deliver insights.

Keynote Speakers

• Seema Verma, Oracle Health & Life Sciences
• Julie Murchinson, Transformation Capital

Advanced Primary Care at a Turning Point: What’s Changing, What Matters and What’s Next

This session sets the stage for where primary care is headed—and why this moment matters. Grounded in NCQA’s advanced primary care work, panelists focus on the major patterns reshaping primary care today—from evolving care models and incentives to changing expectations and the role of technology.

Keynote Speakers

• Asaf Bitton, Ariadne Labs
• Anna Flattau, Thomas Jefferson University
• Kyu Rhee, National Association of Community Health Centers (NACHC)
• Daniel Stein, Embold Health, Inc

Quality in Action: Health Plan Focus on Quality 

A strategic conversation with health plans about how they operationalize quality—aligning mission and measurement, leveraging data and driving performance during the most critical quality periods of the year. Panelists will also explore the future of NCQA’s Health Plan Accreditation, including how this program is evolving to reflect new expectations around outcomes.

Keynote Speakers

• Dana Erickson, Blue Cross Blue Shield of MN
• Andrew Bindman, Kaiser Permanente
• Kelvin Holloway, Georgia Department of Health Medical Assistance Plans

Aligning Payment and Measurement: Do Current Incentives Support Quality Behavioral Health Care?

This session examines the real-world challenges of integrating behavioral health into primary care, with a sharp focus on reimbursement barriers that limit adoption and scale. The discussion will also spotlight a path forward: aligning quality measurement with clinical reality to better reflect team-based, whole-person care.

Keynote Speakers

• Julie Seibert, NCQA
• Carin Skapars, Carelon Health

CMS Vision for Quality and Access

Get an insider’s view into how innovation and technology are reshaping Medicare and Medicaid to advance quality and outcomes for beneficiaries. This keynote will also highlight current initiatives, opportunities and what’s ahead across federal programs.

Keynote Speakers

• Dora Hughes, Centers for Medicare & Medicaid Services (CMS)
• Vivek Garg, NCQA

No More Hype: Turning AI into Better Quality and Outcomes

AI has dominated headlines—but many organizations still struggle to move from experimentation to meaningful impact. This keynote challenges the status quo and focuses on what it really takes to turn AI implementation into better quality and outcomes.

Keynote Speakers

• Shiv Rao, Abridge
• Mark Sendak, Vega Health
• Ari Robicsek, NCQA
• Daniel Yang, Kaiser Permanente

View the full list of sessions here.

Join Us in Atlanta!

The NCQA Health Innovation Summit is the healthcare quality conference built for industry leaders seeking practical solutions—not just theory. It is your opportunity to:

• Join conversations about today’s most pressing healthcare quality issues.
• Connect with NCQA subject matter experts during and after sessions for deeper learning.
• Take part in guided discussions that foster collaboration and actionable ideas.
• Network in the relaxed settings of the Opening Reception and Business Lounge.

Whether this is your first summit or you are returning, you will leave with new perspectives and connections that move your work forward.

Visit our website to learn more and reserve your spot today.

The post Counting Down to the Health Innovation Summit: Join Us in Atlanta appeared first on NCQA.

The current TRC measure assesses performance through a hybrid reporting methodology that combines administrative claims data and medical record review for a sample of eligible members. Because the hybrid TRC measure is included in the CMS Medicare Star Ratings, NCQA is coordinating this effort with CMS and other stakeholders.

“This measure is important because it evaluates care transitions, which present opportunities for missed connections that often require patients and families to fill in the gaps,” says Fern McCree, Director of Digital Quality Informatics at NCQA. “We know that health plans, technology vendors and policymakers are heavily invested in this measure, so we want to be as transparent as possible and allow organizations enough time to prepare for the changes.”

The earliest implementation of the new ECDS TRC measure would be Measurement Year (MY) 2028, with the intention of retiring the hybrid version of the TRC measure in MY 2029.

Building on Existing Standards

The current TRC measure relies heavily on medical record data. As NCQA develops a framework for the new measure, we are evaluating how nationally recognized interoperability standards and terminology, such as Fast Healthcare Interoperability Resources (FHIR^®) and the United States Core Data for Interoperability (USCDI), can support key transitions of care concepts.

Current terminology and administrative code sets, such as LOINC, CPT, HCPCS, SNOMED CT, UBREV and CPT Cat II, support many transitions of care activities. However, some measure components cannot currently be represented using these standards.

“The hybrid Transitions of Care measure has multiple components, some of which may not directly translate to electronic clinical data,” says McCree. “Our ECDS measure development process needs to solve for that while making sure the measure remains useful and meaningful.”

Manual Workflows Add Complexity

While many transitions of care concepts are supported by existing standards, data collection and exchange often depend on manual processes. Through interviews with health plans, care delivery organizations and technology vendors, NCQA identified the following challenges:

• Admission notifications are often automated through admission, discharge, transfer (ADT) feeds, but there is no automated workflow that incorporates those notifications into the patient’s medical record.
• Discharge information is often captured through manual workflows, such as sending faxes and uploading PDFs into medical records.
• Information is not always exchanged, integrated or made accessible in ways that support efficient care coordination or automated quality reporting.

As the interoperability landscape continues to evolve, standards development organizations, federal initiatives and industry collaboratives are actively working to expand and refine interoperability standards and implementation guidance.

What Organizations Can Do Now

As NCQA continues to explore a TRC measure that leverages the ECDS reporting method, we encourage health plans to begin preparing now by identifying opportunities to reduce manual workflows and increase the availability of structured clinical data.

Here are some practical steps organizations can take to prepare:

• Understand how information is exchanged between clinicians, facilities, health plans and technology partners.
• Evaluate where transitions of care workflows rely on manual processes (e.g., fax, manual chart abstraction).
• Look for opportunities to increase automation and reduce manual handoffs during transitions of care from inpatient settings.
• Identify whether key transition and follow-up activities are documented in structured data formats.
• Engage with EHR vendors, interoperability partners and care delivery networks to identify ways to capture, exchange and make data available across systems.

“The one piece of advice I have for health plans is to get started now,” says Tricia Elliott, Vice President of Quality Implementation at NCQA. “Many of the foundational elements needed for digital quality measurement are also valuable for improving care coordination for your population today.”

Looking Ahead

NCQA will continue to work with CMS and other stakeholders as we develop the new ECDS TRC measure specification. Public comment is an important part of the measure development process and organizations will have the opportunity to review and provide feedback on the proposed measure specification before it is implemented.

Learn More

Visit our website to learn more about the transition to ECDS reporting. Submit questions to us through My NCQA.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

FHIR^® is a registered trademark of Health Level Seven International and its use does not constitute endorsement by HL7.

The post The HEDIS® Transitions of Care Measure Is Moving to ECDS Reporting: How You Can Start Preparing Now appeared first on NCQA.

To become a CCBHC and maintain funding, organizations must meet Substance Abuse and Mental Health Services Administration (SAMHSA) certification criteria that evaluate key components of service delivery such as staffing, accessibility of services, care coordination, quality improvement and governance.

NCQA launched a CCBHC Accreditation Program in 2024 to help CCBHCs demonstrate the value of their work, evaluate program quality and ensure continuous quality improvement.

“As standards for CCBHCs become more rigorous, and more states opt to maximize Medicaid for CCBHC funding, there is a need for independent accreditation—beyond self-attestation,” says Jeni Soucie, Senior Manager of Product Management at NCQA. “We want to support CCBHCs in the important work they are doing in the community and amplify their efforts.”

Two Organizations Achieve NCQA CCBHC Accreditation

NCQA is pleased to announce that two organizations have recently earned CCBHC Accreditation.

B&D Integrated Health Services

Established in 2005, B&D Integrated Health Services (B&D) provides comprehensive, integrated primary care, behavioral health and substance use services to more than 2,200 people annually. Its mission is to meet the diverse needs of the community by using approaches that are flexible, person-centered, family-focused, culturally responsive and empirically based. B&D demonstrates its commitment to patient-centered care by including patients on its Board of Directors, ensuring their voices guide its future direction.

B&D is one of five CCBHCs funded by the North Carolina Department of Health and Human Services. Achieving NCQA Accreditation helps B&D stand out and demonstrate to payers, patients and other stakeholders that it is meeting the SAMHSA standards and providing high-quality care to patients.

“We collaborate with the four other grant-funded CCBHCs in North Carolina, but really there is no gatekeeper saying that we are definitely meeting the criteria,” says Allison Williams, Chief Executive Officer at B&D Integrated Health Services. “So, there’s something rewarding about an organization like NCQA validating our work and saying that we’re definitely meeting the criteria. It’s like yes, you’re doing it right.”

VIP Community Services

Headquartered in the Bronx with facilities across New York City, VIP Community Services (VIP) provides a comprehensive network of support for individuals facing complex health and social challenges. More than 70% of its patients are enrolled in Medicaid and have incomes below the federal poverty guidelines. VIP serves a diverse, multilingual population, including Spanish-speaking and African immigrant communities.

As a multi-service organization, VIP provides integrated primary care and behavioral health services, wraparound housing and shelter programs, vocational training, addiction treatment services and residential substance use disorder programs. Earning NCQA Accreditation instills a continuous quality improvement mindset across the organization and better positions VIP for success in value-based contracting.

“Accreditation is not just going through a process. It is about making transformative changes in your organization,” says Debbian Fletcher-Blake, President and CEO of VIP Community Services. “It’s not just a nice thing to do, it is the right thing to do if you really want to improve the care and services that are provided to the people and the communities you serve.”

Benefits of NCQA’s CCBHC Accreditation

NCQA’s Accreditation program provides a streamlined survey process for CCBHCs. We mapped the 113 SAMHSA criteria to 44 standards to make it easier for CCBHCs to structure their programs. Even though the total number of standards has been reduced, all SAMHSA-required components are addressed. We also developed a readiness assessment and a community needs assessment template that CCBHCs can use to help demonstrate compliance.

“This is more than an Accreditation program; it is about creating infrastructure and capacity in the local delivery system,” said Soucie. “Our program provides tools, templates and education to set CCBHCs up for success, which is important as the CCBHC model continues to grow.”

Advice for CCBHCs Pursuing Accreditation

Our first two Accredited CCBHCs have many suggestions for other organizations interested in pursuing NCQA Accreditation.

• Gain leadership buy-in. “We were lucky because we had leadership buy-in from the beginning, and that is very important,” says Darcia Bryden-Currie, Senior Vice President and Chief Clinical Officer at VIP. “It is also critical to engage your multidisciplinary teams early on in the process so everyone sees that Accreditation is an investment in the organization.”
• Focus on the opportunities. “Every organization is going to find areas that need to be improved or strengthened,” says Barbara Salcedo, Director for Quality Improvement Informatics at VIP. “I would advise organizations to lean in and see how close you can come to being that center of excellence for the people you serve.”
• Leverage NCQA’s tools and templates. “We appreciated NCQA’s guidance related to our community needs assessment and we updated our methodology based on their input,” says Williams. “Having a more comprehensive needs assessment is going to inform our strategic planning and ultimately impact the people and communities we serve.”
• Utilize periodic check-ins. “We valued the structure of the three check-ins with NCQA. The feedback we received through that process was very supportive,” says Tanya Hinckle, Quality Management Director at B&D. “NCQA wants us to be the best CCBHC we can be, and they really gave us that foundation. It was very positive.”
• Celebrate your accomplishments. “We display our certificate at our front desk and I think it helps our employees understand how important it is,” says Erin Lewis, Clinical Director at B&D. “It also provides legitimacy for patients and other folks coming in to see that stamp of approval of quality.”

Learn More

• Visit our website to learn more about CCBHC Accreditation.
• Purchase a copy of the CCBHC Accreditation standards in the NCQA Store.
• Contact NCQA’s public policy team to learn more about how NCQA Accreditation can evaluate and improve the quality of CCBHCs in your state. 

The post NCQA Applauds the First Two Organizations to Earn CCBHC Accreditation appeared first on NCQA.

“We have an enormous opportunity to continue to shift quality and performance measurement toward the things that people experience in their day-to-day lives and to empower patients to express what quality means to them,” says Dr. Vivek Garg, NCQA’s President and CEO. “Including person-centered outcome measures in HEDIS represents an important step forward, supporting health plans and care delivery organizations in focusing on what truly matters to patients.”

What Are PCO Measures?

NCQA developed the PCO measures to work in tandem with clinical care, helping older adults and other people living with complex care needs make progress toward a goal that matters most to them. The measures have gone through extensive testing and have been implemented with over 30,000 patients, 750 clinicians, 40 care delivery systems and 17 states.

The PCO measures fit within the broader context of an age-friendly health system because they focus on what matters to the individual and their family and caregivers, which is the “What Matters” of the 4M’s of age-friendly care.​

The PCO measures are approved for inclusion in HEDIS MY 2027 and will be reported using the Electronic Clinical Data Systems (ECDS) reporting method. The three measures are:

1. Goal Identification (GID-E). The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal.
2. Goal Follow-up (GIF-E). The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and followed up on the goal.
3. Goal Achievement (GIA-E). The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and achieved the goal.

Note: GIA-E will remain in first-year reporting status for at least two years, so 2030 would be the earliest year for public reporting of this measure.

How Are PCO Measures Relevant to Special Needs Plans?

NCQA chose to implement PCO measures with special needs plans because of the close alignment with existing care delivery practices and the Model of Care required by the Centers for Medicare & Medicaid Services. We interviewed seven plans, including both C-SNP and D-SNP, to gather insights to inform the integration of PCO measures into HEDIS.

“Feedback from the plans was generally positive. The PCO approach aligns with the SNP mission to deliver person-centered care and existing workflows around goal setting and care plans,” says Daniela Lawton, NCQA’s Assistant Vice President of Quality Sciences Integration. “Some plans were concerned about the implementation timeline, potential burden on clinicians and the challenge of trying to contact all members for goal setting, and NCQA considered this feedback as we developed our strategy.”

Earlier this year, NCQA tested the PCO measures with two D-SNP plans to confirm that the measures are feasible, adaptable to diverse systems and capable of driving person-centered care. Read our blog, NCQA Tests Person-Centered Outcome Measures With D-SNP Plans, to learn more about the testing and get tips for how to implement the measures.

How Did NCQA Incorporate Public Comment Feedback?

Public comment is an important step in the process of adding new measures to HEDIS. NCQA received comments about the PCO measures from 91 individuals and organizations and the majority of comments were supportive. Positive comments cited that the measures capture meaningful outcomes, support whole-person care, align with existing policy requirements and fill a measurement gap for people with complex needs.

One area of concern relates to feasibility, data capture and interoperability challenges. That’s why NCQA co-developed the Person-Centered Outcome Implementation Guide to provide direction for reporting goals and the PCO measures using FHIR^® resources. It includes the steps to document goal-directed care, such as recording a goal, using goal attainment scaling or a patient-reported outcome measure to track goals over time and goal follow-up.

Another concern relates to the administrative burden of the measures—both on health plans and clinicians. The alignment between PCO measures and the CMS Model of Care is achieved by leveraging existing care management workflows and documentation processes wherever possible. NCQA’s testing with D-SNPs demonstrated that organizations can implement the measures without substantial burden. We also pushed back the potential to publicly report Goal Achievement (GIA-E) to no earlier than 2030 to allow plans time to focus on the process of setting standardized goals and following up on them.

“PCO measures have been tested a great deal and they’ve been tested successfully,” says Lawton. “We are excited to release them in HEDIS MY 2027 and we hope to expand implementation of the PCO measures for other populations, including people with behavioral health conditions.”

Learn More

Visit our website to learn more about the PCO measures and how to implement them in your organization.

Acknowledgements

NCQA developed person-centered outcome measures with support from The John A. Hartford Foundation, The SCAN Foundation and the Gordon and Betty Moore Foundation.

We appreciate support from corporations and foundations that share our values and are committed to advancing our mission to improve the quality of healthcare. For more information about partnership opportunities, please contact Erin Oganesian, Assistant Vice President, Quality Solutions Group at eoganesian@ncqa.org.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HL7^® and FHIR^® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

The post Person-Centered Outcome Measures Are Approved for HEDIS MY 2027 appeared first on NCQA.

For HEDIS Measurement Year (MY) 2027, NCQA introduced several updates:

• Added 6 new measures.
• Updated 3 existing measures.
• Transitioned 1 measure to Electronic Clinical Data Systems (ECDS) reporting.
• Restructured ECDS-reported measures reorganized by clinical domain.
• Made minor adjustments made across multiple measures.

New HEDIS Measures

The newest additions to HEDIS address follow-up after a positive colorectal cancer screening, prenatal syphilis screenings, person-centered outcome goals and the use of continuous glucose monitoring.

Two Screening Measures

Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test (COF-E). The percentage of persons 45–75 years of age who received a colonoscopy for a positive colorectal cancer non-invasive screening test.

Intent: Timely follow-up after a positive non-invasive colorectal cancer screening test helps complete the screening process and supports earlier detection and treatment. Delays in follow-up can reduce the value of screening and postpone treatment, increasing both cancer risk and mortality.

• The United States Preventive Services Task Force (USPSTF) recommends colorectal cancer screening for adults aged 45–75 years using stool-based or visual-structural tests.
• Follow-up requirement. A positive non-invasive screening test requires a colonoscopy to complete the screening process.
• Clinical importance. Successful cancer prevention and detection depends on timely follow-up after abnormal screening results.

Prenatal Syphilis Screening (PSY-E). The percentage of deliveries that had a syphilis screening during the first trimester or within 14 days of the first pregnancy diagnosis or prenatal visit or within 30 days of enrollment in the organization.

Intent: Prenatal syphilis screening helps identify and treat infection early in pregnancy, reducing the risk of congenital syphilis in newborns.

• The USPSTF recommends screening pregnant individuals for syphilis early in pregnancy or at the first prenatal visit.
• Clinical rationale. Untreated syphilis acquired before or during pregnancy can lead to congenital syphilis, with a transmission frequency of up to 90%. (1)
• Public health trend. Syphilis rates in pregnancy have risen sharply: In 2024, 3,941 infants were born with congenital syphilis—a nearly 700% increase from 2015, when 495 cases were reported. (2)

Three Person-Centered Outcome Measures

Person-Centered Outcome—Goal Identification (GID-E).

Person-Centered Outcome—Goal Follow-Up (GIF-E).

Person-Centered Outcome—Goal Achievement (GIA-E).

These measures assess the percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal, followed up on the goal and achieved it. They are found under the care coordination subdomain and are specified for reporting by members enrolled in Special Needs Plans (D-SNP and C-SNP). This is the first year that HEDIS Volume 2 will include the person-centered outcome (PCO) measures.

Intent: The PCO measures help individuals and/or caregivers work with clinicians to identify, track and achieve meaningful, measurable goals that support care planning, quality improvement and clinician accountability.

• Care alignment. Person-centered outcomes support whole-person care by aligning care delivery with individual goals and preferences.
• Clinical value. Goal-based care helps clinicians understand the outcomes individuals value, along with their preferences regarding conditions, possible treatments and tradeoffs. (3,4)
• For additional information, refer to NCQA’s person-centered outcome measures resource page.

One Utilization Measure

Continuous Glucose Monitoring Utilization for Patients With Diabetes (CGD-E). The percentage of persons 18–75 years of age with diabetes on insulin therapy who have evidence of continuous glucose monitoring (CGM) utilization during the measurement period.

Intent: CGM supports diabetes management by helping individuals and clinicians identify glucose trends, respond to hypoglycemic and hyperglycemic events and reduce the risk of serious diabetes-related complications. This utilization measure provides transparency into CGM utilization patterns and may help stakeholders identify potential gaps in CGM use.

• The American Diabetes Association recommends CGM use at diabetes onset and throughout treatment for adults using insulin therapy. (5)
• Utilization gap. Despite these recommendations, CGM use remains low among recommended populations and varies across subpopulations and payers.

Changes to Existing HEDIS Measures

Pharmacotherapy Management of COPD Exacerbation (PCE). Updated the measure to assess the percentage of persons 40 years of age and older who had a chronic obstructive pulmonary disease (COPD) exacerbation during the measurement period and were dispensed appropriate COPD medications.

Intent: The PCE measure was updated to align with the 2025 Global Initiative for Chronic Obstructive Lung Disease (GOLD) pharmacotherapy recommendations for patients who experience COPD exacerbations.

• Denominator changes. The measure transitioned from an episode-based denominator to person-based (meaning a member can only be reported in the measure once). The denominator now counts the number of persons who had a qualifying COPD exacerbation event during the measurement period.
• Exclusion changes. The measure now has an exclusion for persons with a comorbid diagnosis of asthma. Clinical guidelines state that individuals with comorbid asthma and COPD should prioritize asthma treatment recommendations over COPD treatment.
• Numerator changes. The measure now looks for dispensing events of appropriate COPD medications during the measurement period. This includes the timeframe prior to the COPD exacerbation event identified in the denominator.

Note: The PCE measure will be in first-year status for MY 2027 due to changes made during the re-evaluation.

Adult Immunization Status (AIS-E). Updated the pneumococcal indicator denominator age range to 50 and older and added two new age stratifications (50–64 and total), which will be reported in addition to the current 65 and older stratification.

Emergency Department Utilization (EDU). Added the Medicaid product line for members 18–64 years of age.

Cross-Cutting Topics

Death Exclusion. Expanded the death exclusion criteria to include persons who died any time on or before the last day of the measurement period.

Changes to the Order of Measures. Removed the Measures Reported Using Electronic Clinical Data Systems domain. Measures from this domain are now located in clinically specific domains (for example, Breast Cancer Screening (BCS-E) is now found under the Prevention and Screening subdomain).  

Race and Ethnicity Stratification Reporting. Updated the race and ethnicity stratification categories and data element tables to capture declinations and unknown race and/or ethnicity more precisely.

Palliative Care Exclusion. Modified the value sets and codes used to identify this exclusion.

ECDS Reporting

NCQA will allow voluntary ECDS reporting for the Glycemic Status Assessment for Patients With Diabetes (GSD-E) measure. Click here for information about the transition to ECDS reporting.

Measures Under Consideration for Retirement in MY 2027 

NCQA is evolving HEDIS to better reflect where quality measurement is headed: toward a more focused, meaningful measure set that delivers clearer, more actionable signals and supports improvement in care, accountability and value across the healthcare system. Measure retirement is an important part of this ongoing curation work, helping ensure that HEDIS adapts to advances in evidence, clinical practice, data availability, policy priorities and stakeholder needs.

NCQA is evaluating the following measures for potential retirement as part of its ongoing measure curation process:

• Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC).
• Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD).
• Diagnosed Mental Health Disorders (DMH).
• Diagnosed Substance Use Disorders (DSU).
• Documented Assessment After Mammogram (DBM-E).
• Language Description of Membership (LDM).
• Oral Evaluation, Dental Services (OED).
• Risk of Continued Opioid Use (COU).
• Topical Fluoride for Children (TFC).
• Use of Opioids at High Dosage (HDO).

In HEDIS Volume 2, these measures are listed as “Pending Retirement” in the “What’s New in Volume 2” section and also alongside each measure name in the individual measure specification. The decision to retire these measures is not final and is pending public comment, followed by a Committee on Performance Measurement review in September. If approved, these measures will be removed from HEDIS MY 2027 Volume 2 during the March 2027 Technical Update.

New Specification Enhancements Coming for MY 2028

With the release of MY 2027 Volume 2, NCQA has released a memo introducing specification enhancements planned for MY 2028. Two example HEDIS measure specifications, Prenatal Syphilis Screening (PSY-E) and Colorectal Cancer Screening (COL-E), are included to show the planned enhancements. The enhancements clarify data source expectations and promote consistent translation of narrative specifications into computable logic, while preserving current reporting and audit practices. These improvements are a continuation of the HEDIS digital measurement transition that started with the release of the ECDS reporting method.

Learn More

Get the HEDIS MY 2027 Volume 2: Technical Specifications in the NCQA Store. The publication purchase will include the new specification enhancements memo and example measures.

Visit the Digital Quality Hub to learn about the transition to digital quality measurement.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

References

1. Pérez-Cavazos, Samantha, María Mayela Rodríguez-Saldívar, Abiel Homero Mascareñas-De los Santos, and José Iván Castillo-Bejarano. “Congenital Syphilis: The Irrevocable Burden of a Late Diagnosis.” Pediatrics & Neonatology 63 (3): 306–7. https://doi.org/10.1016/j.pedneo.2021.10.006.
2. Centers for Disease Control and Prevention. (2025). Sexually transmitted infections surveillance, 2024 (provisional).
3. Lenzen, S. A., Daniëls, R., van Bokhoven, M. A., van der Weijden, T., & Beurskens, A. (2017). Disentangling self-management goal setting and action planning: A scoping review. PLoS ONE, 12(11). https://doi.org/10.1371/journal.pone.0188822
4. Vermunt, N. P. C. A., Harmsen, M., Westert, G. P., Olde Rikkert, M. G. M., & Faber, M. J. (2017). Collaborative goal setting with elderly patients with chronic disease or multimorbidity: A systematic review. BMC Geriatrics, 17(1), 167. https://doi.org/10.1186/s12877-017-0534-0
5. American Diabetes Association. (2026). Continuous Glucose Monitors. https://diabetes.org/advocacy/cgm-continuous-glucose-monitors

The post HEDIS® MY 2027: What’s New, What’s Changed, What’s Retired appeared first on NCQA.

The HEDIS MY 2027 Technical Specifications for Long-Term Services and Supports Measures is a set of HEDIS measures designed to assess whether LTSS organizations are delivering high-quality, person-centered care.

The specifications include a set of four measures that evaluate the quality of assessment, care planning and care coordination for organizations providing LTSS. These measures facilitate the creation of performance standards, allow for comparison of LTSS quality across programs and establish national benchmarks. LTSS HEDIS measures are reported exclusively using the case management record review method.

Updates to LTSS HEDIS Measures for MY 2027

For HEDIS Measurement Year (MY) 2027, NCQA updated the sampling guidelines and the LTSS measure specification format.

In MY 2027, the guidelines for the case management record review method were updated to include instructions for reducing the sample size based on the prior year’s rate. As with HEDIS Volume 2 sampling, organizations may use a rate calculated from the prior year’s reported rate to determine the sample size.

The LTSS technical specifications have a new format that aligns with the Fast Healthcare Interoperability Resources (FHIR^®) data standard and is similar to current HEDIS ECDS reported measures. The new format gives users all the information they need to calculate a HEDIS measure, in addition to the following updates:

• Integration of the clinical evidence base and general guidelines, reducing the need to reference multiple resources.
• Addition of a “Systematic Sample” section.
• Adoption of new terms, for consistency with FHIR and to reflect how measures are used. For example:

• • Replaced “eligible population” with “initial population.”
  • Replaced “required exclusions” with “denominator exclusions.”
  • Replaced “measurement year” with “measurement period.”

We did not modify the measures’ intent or requirements. Changes should not affect performance results.

New HEDIS Reporting Requirements for Health Plans with LTSS Distinction

For Health Plan Accreditation surveys on or after July 1, 2027, under the Renewal Evaluation Option, NCQA will require organizations with LTSS Distinction to report the two HEDIS LTSS measures listed below annually. Measures will be reported for MY 2027, beginning in June 2028.

• LTSS Comprehensive Assessment and Update (LTSS-CAU).
• LTSS Comprehensive Care Plan and Update (LTSS-CPU).

Organizations must submit audited HEDIS results to NCQA each year by the reporting date in HEDIS Technical Specifications for Long-Term Services and Supports Measures.

Visit our website for more information about LTSS Distinction for Health Plans.

Learn More

• Get the HEDIS MY 2027 LTSS measures in the NCQA Store.
• Visit the Digital Quality Hub to learn about the transition to digital quality measurement.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HL7^® and FHIR^® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

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“Credentialing is an important process to protect patient safety and prevent healthcare fraud, but we know there are bottlenecks in the process that can delay access to care,” says Tsveta Polhemus, NCQA’s Assistant Vice President of Product Management. “We are listening to the market and learning how we can evolve our programs while maintaining trust in the data.”

What Is the Credentialing Collaborative?

The Credentialing Collaborative is a group of leaders representing health plans, technology vendors, credentials verification organizations, data aggregators, care delivery and policy organizations that provide feedback on the current and future state of credentialing. The group held its first meeting in June, and two additional meetings are planned for later this year.

The Collaborative is focused on:

• Reducing inefficiencies in primary source verification and ongoing monitoring of practitioner credentials by building trust in technology and automation.
• Shifting toward continuous monitoring and exception-based review to enable a more efficient recredentialing process.
• Exploring governance and trust frameworks for shared credentialing models to enable safe, reliable reuse of data.
• Identifying criteria for trusted and approved sources of credentialing data to support less arduous credentialing across states.

“Credentialing data is extremely dynamic and there is an opportunity for error as it moves through the system,” says Polhemus. “In order to scale operations and maintain rigor, organizations need automation, especially for large national health plans or virtual care organizations with networks that span all 50 states.”

Feedback from the Credentialing Collaborative will help NCQA modernize its credentialing standards to reflect evolving care delivery models, workflows and technology.

What Has NCQA Learned So Far?

Participants emphasized that credentialing serves an essential purpose: ensuring providers are qualified, competent and safe to deliver care. At the same time, many acknowledged that today’s processes contain significant duplication, manual effort and administrative burden.

Importantly, participants do not view modernization as lowering standards. Instead, they see it as an opportunity to strengthen oversight and eliminate unnecessary work.

Here are some key themes that emerged from the discussion:

Continuous monitoring could transform recredentialing.

Many organizations already perform monthly or near-real-time monitoring of licenses, sanctions, exclusions and other credentialing elements. Participants suggested that continuous monitoring could lower the burden of recredentialing, while acknowledging that certain essential tasks would still be needed (e.g., provider attestations, disclosure questions, assessment of exceptions).

Trust and auditability are essential.

Participants agreed that technology-enabled credentialing processes must be transparent, reproducible and auditable, based on authoritative sources and supported by clear provenance and timestamps. They suggested that future standards should focus less on documenting individual human actions and more on demonstrating that systems and controls function reliably.

Technology requires human oversight.

Participants emphasized that technology should support—not replace—sound oversight. There was broad agreement that routine verification activities can increasingly be automated, while human expertise remains essential for evaluating exceptions, risks and complex situations.

Trusted sources reduce redundant verification activities.

Participants expressed strong interest in expanding the use of authoritative sources, aggregators and approved verification services. Many stakeholders suggested that greater clarity from NCQA regarding approved and equivalent sources and evaluation criteria could reduce confusion and drive broader adoption of modern verification methods.

Alignment promotes efficiency.

Participants highlighted the importance of industry alignment. Many noted that differences across organizations, states and regulatory programs significantly contribute to administrative complexity and provider burden. Greater consistency could help create a more efficient experience for healthcare organizations and practitioners.

Organizational readiness varies.

Organizations that perform credentialing differ in levels of digital readiness and access to technology. As credentialing standards evolve, NCQA needs to create a clear pathway for organizations to change—and allow sufficient time to do so.

What’s Next

Our June convening reinforced stakeholders’ commitment to building a credentialing ecosystem that is more efficient, trusted and responsive to the needs of today’s healthcare system. NCQA uses an evidence-based approach to develop and refine its standards, which includes thorough review and vetting by subject matter experts and public comment.

“These conversations are helping shape NCQA’s understanding of where the market sees opportunity for improvement and where there may be emerging consensus around future directions,” says Polhemus. “We are grateful to the organizations that shared their perspectives and look forward to continuing the dialogue in future collaborative sessions.”

Learn More

Listen to our recent podcast, Credentialing: The Unsung Hero of Healthcare Quality, to learn more about credentialing and its impact on access to care.

Sign up for our mailing list to stay up to date on the progress of the Credentialing Collaborative.

Thanks to Our Partners

NCQA appreciates the insights from the organizations participating in the Credentialing Collaborative.

• Aetna Better Health of Illinois (Medicaid)
• American Medical Association (AMA)
• AmeriHealth Caritas
• Andros Technologies Inc.
• Baton Health
• BlueCross BlueShield of North Carolina
• BlueCross BlueShield of Rhode Island
• BlueCross BlueShield of Tennessee
• Capital Health Plan
• Centene
• Certify
• CHG Healthcare
• Cigna
• Council for Affordable Quality Healthcare (CAQH)
• CoxHealth
• Doctors Healthcare Plans, Inc.
• EXLService Philippines, Inc.
• Federation of State Medical Boards
• Gemini Diversified Services, Inc.
• Greeley
• Health Choice Network
• Health Plan of San Mateo
• Humana
• Johns Hopkins Health Plans
• Kaiser Foundation Health Plan
• KFMC Health Improvement Partners
• Koehler Quality Group, LLC
• Martin’s Point Health Care
• Medical Associates Health Plans
• Medical Mutual of Ohio
• MemorialCare Select Health Plan
• Michigan Department of Health and Human Services
• Molina Healthcare
• MultiCare Health System
• Northwestern Medicine Physician Network
• PrimeWest Health
• Professional Credentials Exchange, Inc
• ProviderTrust
• Quest Analytics
• Regence
• Service Coordination Unlimited (SCU)
• South Texas Physician Alliance
• State of Michigan, Bureau of Specialty Behavioral Health Services
• TECQ Partners, Inc.
• Tenon Consulting Solutions
• The Noble Group
• Trinity Health Livonia Hospital
• UnitedHealth – Optum
• UnityPoint Health – Meriter Hospital
• University of Pittsburgh Medical Center (UPMC)
• University of Utah Health Plans
• Verifiable
• Verisys

The post NCQA Credentialing Collaborative Explores the Future of Credentialing appeared first on NCQA.

NCQA will seek feedback about the proposed retirement of select HEDIS measures for Measurement Year (MY) 2027. These proposed changes are intended to strengthen the HEDIS measure set by identifying measures that may no longer provide strong signals for quality improvement, benchmarking or accountability relative to the burden of continued reporting and maintenance.

The ad-hoc public comment period will be open from August 3 to August 17.

Why Are Measures Being Retired?

NCQA’s measure curation work is guided by a broader modernization strategy focused on advancing HEDIS measures that are meaningful, actionable and aligned with the future of healthcare quality measurement. NCQA evaluated existing measures to determine if updates, retirement or replacement were appropriate. Evaluation ensures HEDIS measures remain evidence-based, clinically meaningful and feasible to implement.

Measures considered for retirement may have limited impact on quality improvement, low actionability, small populations, consistently high performance with little variation, overlap with other measures, significant reporting burden relative to value or reduced alignment with evolving clinical guidelines.  Together, these considerations help ensure the HEDIS measure set remains meaningful, effective and aligned with the needs of the healthcare system.

Why Should You Comment?

NCQA measures are based on published clinical guidelines and best available evidence. As new evidence becomes available and the healthcare system evolves, we evaluate measures to determine when updates, retirement or replacement are appropriate using the process described above.

Public comment is an important part of maintaining the HEDIS measure set. NCQA reviews all comments received during the public comment process and presents results to advisory panels and to the NCQA Committee on Performance Measurement for deliberation. NCQA will communicate final determinations through established channels following completion of its review and approval process.

How Can You Comment?

Public comment will go live on Monday, August 3. We will post the link and more details on our public comment webpage.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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