NCQA’s Continuity & Coordination of Care Moves to Outcomes

By Nancy Ross Bell, RN

Estimated time to read: 4 minutes

NCQA’s Health Plan Rating (HPR) scores are now the key drivers for the Commercial, Medicare, and Medicaid product lines for Renewal Surveys with the 2025 standards on Continuity and Coordination of Care (C&C).  Changes to this standard directly impact the data you collect on the exchange of information between practitioners and across settings (QI 3A), as well as your quality improvement plan (QI 3C). As you read through these highlights, reach out to your MHR Consultant for confirmation on how these changes will affect your survey. 

New in 2025 for QI 3 C&C

Requirements of QI 3 for Commercial, Medicare, and Medicaid product lines are described in:

• Data Exchange for Continuity and Coordination of Care (QI 3A)
• Demonstrating Performance on Continuity and Coordination of Care Measures (QI 3B)
• Improving Performance on Continuity and Coordination of Care Measures (QI 3C)

Who Does this Apply to?

For organizations required to report Health Plan Ratings (HPR) HEDIS measures and are scheduled for Renewal surveys on or after July 1, 2025, data is collected using HPR ratings from MY 2024 for Commercial, Medicare, and Medicaid product lines.

For surveys before July 1, 2025:  You will continue to submit evidence according to your standards at the time of the survey –  HPA 2024.

Annual Collection of Data on the Exchange of Information (QI 3A)

The process for annually collecting data on the exchange of information on C&C for QI 3A Factors 1-3 has not changed. Element A applies to all product lines for Interim and First Surveys.

For organizations undergoing a Renewal Survey (Commercial, Medicare, and Medicaid) and are not required to report HPR measures because of not meeting the threshold of <15,000 members, the organization is unable to demonstrate C&C by the annual HPR ratings and, therefore, must submit a report on data exchange for Factors 1-3 (Scope of Review).

However, there is more!

When a required HPR measure, as listed in QI 3B, receives a designation of NA (small denominator), NB (no benefit), BR (biased rate), NR (not reported), or NQ (not required) from a HEDIS audit, documentation for Element A for Renewal Surveys may be required.  Before we explain some of the differences,  please read below about Measures and Scores.

Measures and Scores (QI 3B)

• For Renewal Surveys, C&C performance is now demonstrated using required HPR HEDIS measures that are reported annually (QI 3B Explanation).
• For organizations required to report HPR measures, NCQA scores each product line brought forth for Accreditation.
• Using the HPR scoresheet for required measures as listed in the QI 3B Explanation, the organization calculates the average rating by product line.

An average rating of 3.0 or higher across all required measures by product line is scored as Met (Scoring).

• Some organizations may not be required to report HEDIS because of low enrollment and choose not to be rated for HPR. Refer to NCQA’s Policies and Procedures for your HPA standards (QI 3B Exceptions).

Examples of Calculating Average Rating (QI 3B Examples)

See how the average rating can differ in these three scenarios.

Example #1: Each of the ten required measures had a numerical rating on the organization’s HPR scoresheet.

• Add the rates and divide by 10. If the average was 3.0 or higher, you   If the average was less than 3.0 across all required measures, you Partially Met (See QI 3 B Scoring).

Example #2: Just eight of the measures had a numerical rating. One measure had a Biased Rate (BR), and one was Not Reported (NR), resulting in both having a rate of 0 (zero) reported on the HPR scoresheet.

• Add the rates and divide by 10.

What is critical to note here is that measures with notations of BR, NR, and NQ, with a score of zero, are still included in the average calculation. (If you did not include them in the average calculation, you would artificially increase your overall scoring for the product line.)

Example #3: Just eight of the measures had a numerical rating. One measure had a Small Denominator (NA), and one had No Benefit (NB). In this case, the HPR may show blank for that measure.

• Add the rates and divide by 8.

Notice how the average rate is calculated between BR, NR, and NQ in Example #2 and NA and NB in Example #3 above.

Clarification on Data Exchange for Renewal Surveys (QI 3A)

So now, what happens to Element A if the required HPR measures are supposed to demonstrate coordination and continuity of care?  Is data collection on the exchange of information still needed?  For Interim and First Surveys, yes. For Renewal Surveys, it depends!

The impact on QI 3A Factors 1-3 when organizations receive designations of NA (small denominator), NB (no benefit), BR (biased rate), NR (not reported), or NQ (not required) from their HEDIS audit on any or all of the required measures as listed in QI 3B, depends on several considerations.

• Was the organization required to submit HEDIS data?
• Did the organization receive an HPR scoresheet for the required measures listed in QI 3B?
• Did any, some, or all rates receive the designations listed above?

For example:   

1. If an organization is required to submit HEDIS data but does not have a valid rate (NR) for any of the required measures and, thus, does not have an HPR scoresheet, then the organization must submit evidence for Element A since the HPR measures did not demonstrate C&C.
2. If an organization receives a score of NA or NB on an individual measure, then the measure is removed from the denominator and not counted towards the 3.0 average calculation, and thus, is not required to submit evidence for Element A because C&C would be demonstrated by the remaining measures on the HPR scoresheet (See Example #3 above).
3. If an organization receives an NR, BR and/or NQ on one or more required measures and the rating of 0 is included in the calculation of the average, then the organization is not required to submit evidence for Element A because C&C would be demonstrated by the remaining measures on the HPR scoresheet (See Example #2 above).

Make note: If you are required to submit HEDIS data but do not receive an HPR scoresheet, you may be at risk of Not Met for Elements A if you have not collected data on Element A for the most recent year.  For example, all measures are scored as NA (small denominators).

If there is a possibility of a large membership drop in a specific product line that may remove the requirements to report Health Plan Ratings measures, MHR recommends proactively collecting the necessary data for QI 3A.

Improvement Plan (QI 3C)

With the average ratings by product line now calculated, the next step is to develop improvement plans by product line and act on at least one required HPR measure rated initially as 1 or 0. 

If the organization did not receive a rating of 1 or 0 on any required HEDIS HPR measure for the product line, then an improvement plan (Element C) is not applicable (NA) (QI 3C Exception).

What must be documented in the C&C Improvement Plan? (See QI 3C Explanation)

For each product line, a documented process includes:

• Identification of measures with a rating of 1 or 0 on the most recent HPR scoresheet(s) by product line
• Actions the organization plans to take to improve each measure’s rating (If appropriate, one action may be used to address multiple measures.)
• How progress will be monitored
• How frequently progress will be monitored
• Parties responsible for performing the tasks (e.g., staff, department, committee)

When developing a C&C Improvement Plan, you may refer to other organizational analyses for insights into subpopulations, health equity needs, availability/accessibility of network providers, value-based payment arrangements, member complaints, grievances, appeals, and experience.

Tying it All Together into the QI Program Structure and Operations

Now is the time to step back and see the bigger picture by integrating C&C into the organization’s overall quality structure.

• Designate the QI Committee and subcommittees responsible for overseeing C&C activities. Update committee descriptions with responsibilities (QI 1A, D).
• Incorporate the C&C Improvement Plan for each product line into the Annual Work Plan (QI 1B) by doing one of the following:
  • Make the C&C Improvement Plan a supplement of the Annual QI Work Plan, or,
  • Keep the C&C Improvement Plan independent from the Annual QI Work Plan. Add and track individual actions in the C&C plan. Monitor that the C&C plan is on track through the Annual QI Work Plan.
• Plan for and conduct an Annual Evaluation of C&C completed and ongoing activities (QI 1C).
• Assess how changes in C&C activities may affect transitions to other care (QI 3E).
• Determine if changes to Delegated Agreements may be warranted (QI 4).
• Communicate new programs and activities to members and providers.

To Read More About the NCQA standards, HPR and HEDIS, please see:

• 2025 NCQA Health Plan Accreditation standards for purchase from the NCQA’s Store
• Health Plan Ratings (HPR) Methodology for Commercial, Medicare, and Medicaid
• About the HEDIS Compliance Audit

Call to Action:

• Step back and let MHR help you see the bigger picture by customizing your QI strategy to maximize your investment in NCQA Accreditation.
• Recharge your organization’s QI focus with MHR’s updated training on the QI 3 Elements.
• Contact your MHR Consultant or [email protected]

MHR follows a quality review process for all blogs. This blog was written with insights from Monique Fields and Kim Carpenter Petit. Please read more about the MHR Consultants at ManagedHealthcareResources.com/About Our Consultants.  

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