PCO measures work in tandem with clinical care to help people living with complex health needs make progress toward a health goal that matters to them. PCO measures have three components:

• Identify a goal and document it in a structured way, using goal attainment scaling or a patient-reported outcome measure.
• Follow up on the goal.
• Assess achievement of the goal.

Clinicians across the care continuum and in community-based services can use this approach to identify what’s important to a person and support age-friendly care. Defining a person’s goals—and ensuring that their care is consistent with those goals—can reduce unwanted treatment, improve patient activation and lead to meaningful improvement.

Why It Matters

NCQA is currently moving the PCO measures for C-SNPs and D-SNPs through the HEDIS^® approval process, with the goal of incorporating the measures in Measurement Year (MY) 2027.  We are beginning with special needs plans because they have an existing practice to build on—they already include goal documentation as part of their care models. Plus, the Centers for Medicare & Medicaid Services (CMS) issued a new rule in August 2025 that requires goals to be person-centered and for care teams to follow up on the goals, which aligns with PCO measures.

“In the past ten years, NCQA has tested the PCO measures with over 30,000 patients and over 750 clinicians in a variety of care settings across 17 states,” says Daniela Lawton, NCQA’s Assistant Vice President of Quality Sciences Integration. “We’ve shown that clinicians are able to implement this approach and organizations are able to document and report the necessary data elements for the measures. We are excited to work toward incorporating the PCO measures into HEDIS.”

In Their Own Words: Partner Perspectives on PCO Measures

Our partners explain why they chose to participate in the D-SNP testing.

“Person-centered outcome measures are crucial for our membership as they empower members to take control of their health. This approach fosters better engagement and collaboration, ultimately leading to improved health outcomes. We volunteered for this testing process because our mission is to make a lasting difference in our members’ lives. Supporting our membership in developing their specific, member-driven goals and needs aligns perfectly with this mission. Through this testing, we have recognized that while members may fall within the same category, their individual needs can vary significantly. Generalized goals do not adequately address these unique needs. By focusing on member-driven and specific objectives, we can truly understand our members and provide the support they need to achieve their goals.”

Meghan Crane, MSW, LISW-S, CCM, Manager, Case Management, Integrated Care, CareSource

“Person-centered outcome measures represent a strategic evolution in how we define value and accountability in healthcare. For the D-SNP populations we serve, quality must extend beyond clinical indicators to reflect the goals, preferences and lived experiences that shape each member’s health journey. Our participation in NCQA’s testing initiative reflects our broader commitment to advancing a more integrated, person-centered model of care. By contributing insights from the communities we serve, we are helping shape the future of quality measurement while strengthening how person-centered principles are embedded across our long-term strategy, partnerships and performance framework.”

Dr. Christy Valentine Theard, President, Anthem Blue Cross and Blue Shield Medicaid, New York

“Person-centered outcome measures are especially important for the vulnerable populations we serve because they center care around what matters most to our members—their personal goals and lived experiences. Person-centered outcome goals help ensure we are supporting quality of life, independence and dignity.”

Esther Elefant RN, BSN, CRC, Director II of Health Care Management Services, Anthem Blue Cross and Blue Shield, New York

Lessons Learned from D-SNP Testing

NCQA evaluated PCO measures with two D-SNPs to assess whether goal conversations and documentation are feasible and can be integrated into existing SNP workflows. We provided technical assistance and reviewed data submissions to identify areas for improvement.

“Our testing confirms that the PCO measures are feasible, adaptable to diverse systems and capable of driving person-centered care,” says Lawton. “Goal identification had the highest compliance among D-SNPs. Performance rates for goal follow-up and goal achievement were lower, which is consistent with our past testing efforts.”

Here are some of the lessons learned that can help clinicians as they prepare to implement PCO measures:

1. Focus on what matters to the person. A patient managing diabetes may be more motivated to feel well so they can attend a family event, rather than focusing solely on lab numbers. Ask probing questions to understand why the goal matters to them.
2. Identify a specific task or activity. Singular goals give people a clear focus. Rather than “get more active,” a person with diabetes might choose walking as the specific activity they want to increase.
3. Set a realistic time frame. All goals should be timebound. For example, walking 10–14 minutes daily for the next two months is more actionable than an open-ended commitment to move more.
4. Don’t expect perfection. Build wiggle room into the patient’s goal, so a missed day doesn’t mean failure. Adding “on average” can also help it feel less daunting. For example, setting a goal to walk 10 minutes daily, on average, over two months leaves wiggle room for a 5-minute or a 15-minute daily walk—giving the patient options without derailing progress.
5. Document all follow up discussions. Goal progress should be documented at every visit—even when the patient hasn’t advanced. During testing, we discovered that some clinicians were not documenting the follow-up conversation if the patient did not make enough progress toward their goal. If progress is stalling, check in: Is the goal still realistic? Use that conversation, not just the outcome, as the clinical record.

What’s Next

NCQA recently completed a public comment period for HEDIS MY 2027, which included a recommendation to add PCO measures for D-SNPs and C-SNPs. Institutional SNPs are not included. Next, the recommendation will move through NCQA’s committee process for consideration and approval.

We also see movement toward digitalization of goal-directed care through Health Level Seven (HL7^®), which presents opportunities to standardize the documentation required for the PCO measures. NCQA is participating in the HL7 Patient Care Work Group and co-developed the Person-Centered Outcome Implementation Guide (IG). The IG defines the standards for transmission of data in an interoperable format, such as Fast Interoperability Healthcare Resources (FHIR^®). It includes the steps to document goal-directed care, such as recording a goal, using goal attainment scaling or patient-reported outcome measures to track goals over time and goal follow-up. The IG should be released in the spring.

Learn More

The graphic below provides a high-level overview of PCO measures and how they work. Visit our resource page to learn more about 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.

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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Colorectal cancer represents approximately 8% of all new cancer cases; it is the third most commonly diagnosed cancer in the United States and the leading cause of cancer deaths in men under 50.¹ Routine screening—through colonoscopy, stool-based testing or other methods—can detect precancerous polyps that can be removed before they develop into a later-stage cancer.

“Many individuals with a positive screening through a stool-based test do not receive the necessary follow-up care, such as a colonoscopy,” says Brenna Lin, NCQA’s Applied Research Scientist. “Ensuring that abnormal screening results are followed by timely diagnostic care is essential to achieving the full benefit of screening. The proposed HEDIS measure is designed to address this quality gap.”

Progress Over the Past Year

NCQA continues its partnership with the Council of Medical Specialty Societies and the American Gastroenterological Association to develop a new HEDIS measure to improve follow-up care for patients who receive positive colorectal cancer stool-based test screening results. The project is funded by the Centers for Disease Control and Prevention.

We advanced the measure through several major development steps:

• Completed a comprehensive review of clinical guidelines and evidence to ensure alignment with current standards.
• Presented the draft measure to three NCQA advisory panels. Their guidance informed refinements to the measure’s intent, specifications and feasibility.
• Conducted field-testing with three partner organizations to assess feasibility, evaluate performance using real-world data and guide updates to measure specifications.

Now Open for Public Comment

The proposed HEDIS measure, Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test, is posted for public comment through March 13. NCQA welcomes feedback from all individuals and organizations who wish to share their perspectives. Public comment is a vital part of the measure development process and helps ensure that new measures are scientifically sound, meaningful and feasible to implement.

Visit our public comment webpage to learn more or to submit your comments.

Acknowledgements

The NCQA Healthcare Effectiveness Data and Information Set (HEDIS) Measures for Colorectal Cancer Screening project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award to the Council of Medical Specialty Societies (CMSS) totaling $1,563,853 with 100 percent funded by CDC/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor endorsement by, CDC/HHS or the U.S. Government.

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

¹National Cancer Institute, 2023.

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NCQA’s Advanced Primary Care Pilot Program is defining the next generation of primary care. Building on what we’ve learned from our Patient-Centered Medical Home (PCMH) Recognition program, the pilot will accelerate innovation, test scalable models and help healthcare organizations meet the needs of diverse communities.

“Primary care is the foundation of a high-quality health system and one of the strongest levers to improve population health and affordability. The organizations participating in this pilot are doing more than testing approaches—they’re helping the entire industry learn and shaping the future of primary care,” said Vivek Garg, MD, MBA, President and Chief Executive Officer at NCQA. “We’re grateful to our primary care partners for leaning in as pilot participants and helping advance this work for primary care and patients alike.”

Which Organizations Are Participating in the Pilot Program?

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’re pleased to announce our primary care partners:

Aledade

Bluegrass Community Health Center

Jefferson Health

NYC Health + Hospitals

Hear directly from some of the participating organizations about why they chose to join the pilot program and how it will improve care for patients.

“True systemic change in healthcare starts and ends with primary care. Every day, we see how primary care practices transform lives when they are empowered with the right data and a true value-based model. Through this effort we are proud to bring our decade of experience to help shape a quality standard that emphasizes what actually matters for primary care: preventing illness, serving communities, and delivering better care at a lower cost for everyone.”

Farzad Mostashari, MD, Co-Founder and CEO, Aledade

“Bluegrass Community Health Center appreciates the opportunity to collaborate with NCQA on the Advanced Primary Care pilot. As an FQHC, we are committed to models that recognize the depth of our work while remaining practical and sustainable. This pilot is an exciting opportunity to help shape a meaningful, usable program that supports primary care without adding unnecessary burden.”

Brandy Coyle, MBA, BS, RN, Chief Compliance Officer, Bluegrass Community Health Center

“As a large academic health system, Jefferson Health deeply values primary care as foundational to individual, family, community and public health across the many communities we serve. Quality measures shape the daily efforts of our clinical teams, and they articulate the value of primary care’s complex work to stakeholders within and beyond healthcare. We appreciate NCQA’s leadership in bringing on-the-ground voices from diverse organizations to help redefine the nation’s approach to primary care quality metrics.”

Anna Flattau, MD, MS, System Chief for Primary Care and Chair of Family and Community Medicine, Jefferson Health

What’s Involved in the Advanced Primary Care Pilot Program?

The PCMH model demonstrated that primary care practices can mature and deliver better outcomes at lower costs, but they must consistently invest in care delivery, data infrastructure and workforce to keep pace with evolving payment and performance expectations. The Advanced Primary Care Pilot Program will build the next step of primary care’s evolution.

“Today, there is no common definition of what ‘advanced’ primary care truly means, and expectations vary across the industry,” says Jeff Sitko, AVP, Product Management at NCQA. “As primary care takes on growing clinical and financial accountability, clearer shared expectations between plans and practices are essential. Through this pilot, we’re testing these concepts in real-world settings and defining a shared roadmap for how primary care capabilities mature, supporting more integrated, data-driven models that strengthen collaboration, advance behavioral health integration and deliver measurable improvements in outcomes.”

NCQA has developed a preliminary set of standards for primary care organizations. Pilot participants will implement and test these standards within their organizations and help identify what is both valuable and realistic. They will also report on a standardized set of electronic clinical quality measures appropriate for their populations and assess the feasibility of reporting digital quality measures.

At the end of the pilot, the four organizations will be rated on their overall results through a “mock survey” process, and they’ll make recommendations about how NCQA should adjust and evolve the standards and measures in the future.

“We’re excited to bring these organizations into the test kitchen with us to determine what actually matters to them,” says Sitko. “Let’s get rid of the ‘fluff’ so we’re not asking delivery systems to check boxes and perform activities procedurally that don’t actually bring value at the end of the day. And let’s make sure we’re anchored in those areas that positively impact clinical outcomes for patients.”

The ultimate goal is to create a clearer path to integrated, data-driven team-based care that enables primary care to thrive in advanced payment models and strengthens the relationship between payers and primary care.

What’s Next

We’ll share the results of the pilot program later this year, along with details about how NCQA plans to enable the next generation of primary care.

In the meantime, listen to our Quality Matters podcast, What’s New and What’s Next for Primary Care, featuring Jeff Sitko and Karen Johnson, Vice President, Practice Advancement for the American Academy of Family Physicians.

The post NCQA Launches Advanced Primary Care Pilot Program—Meet Our Primary Care Partners! appeared first on NCQA.

“The growing prevalence of CKM syndrome and its widespread impact on population health signals the need for a unified framework that integrates prevention, treatment and quality measurement,” says Adrianna Nava, PhD, RN, NCQA’s Applied Research Scientist. “NCQA sees an opportunity to transform CKM care from fragmented, disease-specific management to holistic, patient-centered approaches.”

Our Approach to Evaluating CKM Care

In 2025, NCQA convened three meetings to address the challenges associated with CKM syndrome. The first meeting focused on ways to improve the quality of care for people with chronic kidney disease. The Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework white paper captures the dynamic discussions and insights from this convening.

The second and third meetings reconvened the roundtable participants to discuss ways to improve the quality of care for CKM syndrome. The new white paper, Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability, captures insights from these convenings.

The white paper outlines a comprehensive approach to improving the quality of CKM care and accountability. It explores five key domains essential for transforming CKM care.

1. Defining ideal care, identifying feasible CKM measures and breaking down silos.
2. Clinical integration, risk stratification and life course perspectives.
3. Patient and community engagement.
4. Technology as a driver of CKM syndrome.
5. Payment reform, health plan and health system coordination.

NCQA gathered input from experts representing a wide variety of disciplines: primary care, pediatrics, nephrology, cardiology, endocrinology, internal medicine, epidemiology, pharmacy, geriatrics, nutrition, gastroenterology, lifestyle medicine, nursing, hepatology, diabetes education, informatics and health policy. The convenings also included three patient advocates who provided valuable input based on their personal experiences with severe kidney disease and diabetes.

Key Findings and Recommendations

This report proposes a framework for improving CKM care quality through measurement and accountability. Recommendations include:

• Measure Integration and Alignment. Reduce the emphasis on process-oriented metrics and develop and promote intermediate outcomes like BP, HbA1c and uACR that are aligned with CKM risk stages and can be tracked over time.
• Risk-Based Framework. Use evidence-based tools and risk calculators to guide early detection, prevention and precision management.
• Cross-Specialty Accountability. Embed CKM coordinators, shared care plans and multidisciplinary documentation to align specialties around shared outcomes.
• Patient-Reported Outcome Measure (PROM) Integration. Incorporate PROMs assessing self-efficacy, health outcome goals, treatment burden and quality of life into performance frameworks.
• Technology Modernization. Invest in interoperability, predictive analytics, remote monitoring and automation to support proactive care.
• Social Determinants of Health Focus. Integrate social needs screening, referral tracking and community partnerships to close disparities.
• Value-Based Payment. Link reimbursement to intermediate outcomes and progression metrics that reward health plans and systems for prevention and coordination.

By aligning professional guidelines, technology and payment systems within an integrated CKM syndrome measurement framework, CKM syndrome care can become a coordinated, holistic and equitable continuum. This approach will not only improve patient outcomes; it will also strengthen accountability, reduce healthcare costs and create a foundation that supports active collaboration among providers, health plans and other stakeholders.

“CKM syndrome is one of the most pressing and complex challenges that clinicians, health systems and health plans face today,” says Nava. “The white paper provides an actionable roadmap for developing a CKM measurement framework that supports whole-person care, equity and sustainability.”

The insights and recommendations gathered from these convenings will guide NCQA in shaping a comprehensive quality improvement framework for CKM syndrome. As this work progresses, NCQA is eager to partner with national stakeholders to drive alignment, strengthen community collaborations and build consensus around a CKM-focused primary care framework for the next phase of this initiative.

To get involved in the next phase of this work, please contact Erin Oganesian, AVP, Corporate & Foundation Relations at eoganesian@ncqa.org.

Learn More

• Download the white papers: Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework and Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability.

Acknowledgments

Thank you to our panel of experts for sharing their knowledge and insights. This research is made possible with support from Boehringer Ingelheim and Novo Nordisk.

The post NCQA Releases New White Paper on Improving Quality of Care for Patients with CKM Syndrome appeared first on NCQA.

“We started developing PCO measures in 2015 to improve healthcare for patients with complex care needs,” says Julie Seibert, NCQA’s Assistant Vice President, Behavioral Health. “This project builds upon that work by updating the measures for adults with IDD and providing practitioners with tools to incorporate quality measures that align with person-centered goals into the treatment process.”

This initiative stems from NCQA’s partnership with IEC (Institute for Exceptional Care) on the IIDDEAL (Individuals with IDD Engaged, Aligned and Leading) project to conduct an environmental scan and work with self-advocates to build consensus on which quality measures are most appropriate and applicable for people with IDD. Read our blog post to learn more about our work with IIDDEAL.

How Can PCO Measures Support People with IDD?

Healthcare for adults with IDD is fragmented, costly and may not reflect what matters most to them. Quality measures can help improve care, yet NCQA’s environmental scan for the IIDDEAL project found only two quality measures that focus on adults with IDD—and many measures that exclude this population.

“Narrowly focused clinical outcome measures fail to capture the full range of treatment needs for people with IDD,” says Seibert. “That’s why it’s important to focus on person-centered goals.”

What Are the Goals of the Project?

Funding from the WITH Foundation will help NCQA collaborate with self-advocates and IEC to refine and adapt the PCO measures and resources for practitioners serving adults with IDD.

The project has three goals:

1. Equip practitioners with tailored tools and training to integrate the PCO approach.
2. Empower adults with IDD to identify person-centered goals.
3. Use PCO measures to assess care provided to adults with IDD.

NCQA will convene expert work groups that include individuals with IDD, caregivers, payers and clinicians serving adults with IDD to review updates to the PCO measures and resources and provide feedback. We will also develop online continuing education to show practitioners how to use the PCO measures and apply best practices for working with adults with IDD.

“We are working toward broad adoption of PCO measures and we’ve already incorporated them into some of our Accreditation and Recognition programs,” says Seibert. “We are grateful to the WITH Foundation for helping us advance the use of PCO measures to provide effective, high-quality, person-centered care for people with IDD.”

Learn more about NCQA’s PCO measures and their impact.

About the WITH Foundation

The WITH Foundation is committed to transforming healthcare to make it more inclusive and equitable for people with IDD. Since 2002, it has awarded over $17 million in funding to support organizations and projects that promote comprehensive and accessible healthcare for adults with IDD. Visit the WITH Foundation website to learn more.

The post NCQA Receives WITH Foundation Grant to Expand Use of Person-Centered Outcome Measures appeared first on NCQA.

The use of digital tools, combining software and hardware technologies to monitor patients remotely, is gaining traction,³ and is proving to be effective at not only managing therapy complications, but also at improving patients’ quality of life and satisfaction.² One such example is the use of Electronic Patient-Reported Outcomes (ePRO), digital tools that let patients report symptoms, side effects and quality-of-life indicators in real time. These tools have shown remarkable promise in oncology settings that can lead to better identification of patients’ needs, improving patient-provider communication, care management, and patient satisfaction, as well as decreased emergency department visits.⁴

At the federal level, in 2023 the Centers for Medicare & Medicaid Services (CMS) launched the Enhancing Oncology Model (EOM), a voluntary, value-based payment model covering Medicare beneficiaries. Lessons learned from a previous model, the Oncology Care Model, led CMS to require the use of ePROs by EOM⁴ participants beginning in performance period 5 (PP5), which corresponds to measurement year 3⁴, to monitor symptomatic toxicities, physical functioning, behavioral health and health-related social needs. Patients submit data via smartphones, tablets, or even voice response systems. The information is then integrated into EHRs, enabling care teams to respond quickly to concerning trends.^4,5

While large hospitals and health systems are often better equipped to implement remote monitoring and use of ePROs for patients, and have the ability to integrate care across specialties, community oncology practices—where most cancer patients get treatments⁶—face unique challenges to ensure integrated, coordinated care. For community oncologists, remote patient monitoring is a scalable way to extend care beyond the clinic. For rural or underserved populations, it bridges the gap between clinic visits and real-world needs, ensuring continuity of care. Data can be shared across teams, improving communication between oncologists, nurses and navigators, and patients report feeling more in control of their care and more connected to their providers.⁶

In a study of a large community oncology practice, the combination of ePRO and other remote monitoring tools demonstrated significant reductions in hospitalizations (39%), emergency department visits and overall cost of care ($1,146 per member per month in average savings per ePRO-monitored patient per month).⁷

The integration of ePROs and remote patient monitoring (RPM) into transitional oncology care represents a shift toward truly patient-centered models. These technologies can empower patients to be active participants in their treatment, reduce unnecessary utilization, enhance communication across providers and improve outcomes across the board.

This blog is brought to you by Johnson & Johnson and the views expressed are solely those of the sponsor.

¹ Patient Satisfaction and Quality of Surgical Care in U.S. Hospitals. Accessed at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4248016/. September 15, 2025

² The association between care integration and care quality, Health Services Research. Volume 59, Issue 6, December 20204. Accessed at: https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.14214. October 25, 2025.

³ Ochsner Chemotherapy Care Companion. Vol. 38, No.3, 2023. Accessed at: www.accc-cancer.org/docs/documents/oncology-issues/articles/2023/v38-n3/ochsner-chemotherapy-care-companion.pdf. September 16, 2025.

⁴ CMS Enhancing Oncology Model ePRO implementation Fact Sheet. Accessed at https://www.cms.gov/priorities/innovation/media/document/eom-epros-fs. September 15, 2025.

⁵ Reflections on the Oncology Care Model and Looking Ahead to the Enhancing Oncology Model. JCO Oncology Practice. Volume 18, No. 10. Accessed at: https://ascopubs.org/doi/10.1200/OP.22.00329#:~:text=One%20of%20the%20primary%20goals,requirements%20and%20drive%20quality%20improvement. September 16, 2025.

⁶ National Cancer Institute. Accessed at: https://www.cancer.gov/research/areas/disparities/chanita-hughes-halbert-clinical-trials-community-access#:~:text=Approximately%2085%25%20of%20cancer%20patients,the%20quality%20of%20their%20care. September 17, 2025

⁷ JCO Clinical Cancer Informatics. Impact of Remote Symptom Monitoring with Electronic Patient-Reported Outcomes on Hospitalization, Survival, and Cost in Community Oncology Practice: The Texas Two-Step Study. Patt, et. Al. Accessed at: https://ascopubs.org/doi/10.1200/CCI.23.00182. October 30, 2025.

The post Empowering Cancer Patients: How ePROs and Remote Monitoring Improve Transitions and Outcomes appeared first on NCQA.

How 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:

• Measures of clinical quality from 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 (NCQA 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 Accredited by NCQA. Learn more about the Ratings methodology here.

Highest-Rated Health Plans by State

Click on the links below to view the highest-rated health plans in each state, U.S. territory or the District of Columbia.

• Alabama
• American Samoa
• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Florida
• Georgia
• Guam
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Carolina
• North Dakota
• Northern Mariana Islands
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Puerto Rico
• Rhode Island
• South Carolina
• South Dakota
• Tennessee
• Texas
• Utah
• Vermont
• Virgin Islands
• Virginia
• Washington
• West Virginia
• Wisconsin
• Wyoming

How to Use the Ratings

NCQA presents ratings in a user-friendly online report card to help people choose the best health plan for their needs. Users can:

• Search for a specific health plan by name.
• Filter health plans based on criteria, such as star rating or location, and compare results across multiple plans.
• Drill into the details to find out how well a plan performed on a specific health topic, like cancer screening or diabetes care.

View the 2025 Health Plan Ratings here.

The post NCQA’s 2025 Health Plan Ratings: Highest-Rated Health Plans by State appeared first on NCQA.

Real-time Visual Notes created by Ink Factory.

Thanks to everyone who attended this year’s Health Innovation Summit and made it a success! And if you couldn’t be there, keep reading for takeaways from the keynote session, Setting the Bar: Quality and Impact in Behavioral Health Innovation.

Moderator Geoffrey Neimark of Community Care Behavioral Health led a conversation with industry experts—Kate McEvoy of the National Association of Medicaid Directors and Michael Tang of Cityblock Health—about the risks and opportunities technology brings to behavioral health, especially for underserved populations.

Many factors contribute to the demand for behavioral health services: COVID pandemic isolation and social disconnection; overuse of alcohol, opioids and stimulants; the destigmatizing of behavioral conditions; increased behavioral health screening; the negative impact of social media. Unfortunately, the increase in demand coincides with a decrease in the number of practitioners.

“Behavioral health is primed to leverage technology to solve some of the access challenges,” says Neimark. “But there are also concerns about quality, equity and trust.”

Leveraging Technology in Behavioral Health

Telehealth is an effective way to improve access to behavioral health and substance use disorder care. Tang shared the story of a patient with schizophrenia who struggled to remember to take his pills every day and wanted to receive his medications through a shot. “I can supervise the patient virtually, even though I’m not in their home. Within minutes, I was on a virtual visit with him to assess his needs and discuss the medication,” says Tang.

McEvoy shared how Medicaid programs have embraced the use of technology to smooth the path to eligibility, improve access to services and supports through telehealth and enable better support and coordination of care for people with complex co-occurring needs.

“We recognize that different entities within state government—Medicaid, child welfare, departments of intellectual disability, the education system—all connect with children and families, but it’s been challenging to share data and coordinate efforts,” says McEvoy. “Interoperability can help identify needs and focus on those with the highest level of acuity.”

Risks of Using Technology and AI

Using AI with patients is a risk. “Many of our members come from minoritized communities and have distrust about new technologies. One of our core principles is that equity has to come first,” says Tang. “AI is part of care, but it’s not just AI by itself. It’s AI and humans working together to build trust and build relationships. We’re defining our AI governance processes and thinking cautiously about having AI work with our members.”

McEvoy also cautioned about the risk of relying too much on technology. “We’ve gone so far down the path with individualized home interventions, especially for older adults. We’re reexamining some programs to make sure we’re not contributing to social isolation, loneliness and depression.”

Technology and Health Literacy

While technology can provide many benefits, it’s not for everyone. Behavioral health organizations need to be thoughtful about how and where they implement technology, and consider limitations on broadband access or digital literacy.

“We’ve been surprised by the level of digital literacy of our members. People are texting and using their smartphones all the time,” says Tang. “But it is also situational. Sometimes our members can’t afford to pay their phone bill, so we need to be flexible and offer different ways for them to access services that are not technology dependent.”

Often, trust isn’t just about technology, it’s about the system itself. Having trusted messengers is also important. Community health workers or peer support specialists that share the same cultural background, speak the same language and have similar lived experience can build trust and, where appropriate, help facilitate the use of technology.

Evaluating the Use of Technology

Behavioral health organizations should consider these questions as they adopt new technologies:

• Who is the technology for—and who might it leave out?
• When is the technology solution appropriate—or inappropriate?
• Is the technology culturally responsive?
• Does the technology assume a certain level of digital literacy?
• How does the technology protect privacy and dignity?

“Technology cannot replace relationships. I’ve long been an advocate of group psychotherapy. It’s effective, it’s cost efficient, it amplifies access and it addresses social disconnection,” says Neimark. “I think we’re going to see a combination of growth in technology and growth in the human connection part of therapy.”

Join Us Next Year

Mark your calendar for the 2026 Health Innovation Summit, October 4–7, in Atlanta, Georgia. We hope to see you there!

The post Technology in Behavioral Health: Risks and Opportunities appeared first on NCQA.

Picture this scenario: A woman with diabetes visits her doctor and receives a prescription. But once she’s home, she struggles. She doesn’t fully understand the instructions for taking the medication because English isn’t her first language, and she doesn’t know anyone who can help her translate. She also worries about being able to afford both the medication and groceries.

On paper, her care plan looks complete—in reality, it’s falling short. That’s why whole-person care matters.

Whole-Person Care Is More Than Responding to Symptoms

Health is shaped by a person’s mental health, daily stresses, cultural background, ability to communicate and more. Whole-person care recognizes these factors and addresses them alongside appropriate medical needs.

When providers account for social and behavioral health factors as well as medical conditions, care becomes more relevant. A care plan that includes counseling, access to food resources and language support is far more likely to help this woman than merely prescribing medication.

Building an Integrated Platform

Of course, care coordination doesn’t happen on its own; it requires an integrated platform that brings together patients, health care professionals and health plans. When information flows, patients don’t have to repeat their stories, and care teams can see the full picture.

An effective platform does more than store data. A truly effective platform:

• Tracks medical, behavioral and social needs in real time.
• Stores language preferences for all health plan members.
• Clearly and succinctly presents the most critical needs relevant to members.
• Sends reminders and prompts so important steps aren’t missed.
• Allows seamless hand-offs between clinicians.

Strong platforms generate insights from member interactions and care delivery, then evolve based on what they learn—that’s what makes them dynamic and valuable. Internal innovation becomes even more powerful when paired with the health plan partner perspective. Plans might see patterns across populations and bring a systemwide view of areas where members struggle. When platform intelligence and partner insights come together, the results are meaningful, providing lasting improvements that make care more connected and effective.

Omnichannel Outreach: Meeting People Where They Are

But even the best-designed platform won’t work if patients aren’t engaged. Omnichannel outreach can fill communication gaps that hinder the ability to provide meaningful care. By offering multiple ways to connect—phone call, text, email, secure messaging portal, letter, home visit—care teams can reach members in ways that fit their daily lives.

For some members, a quick text reminder is enough. For others, a call from a trusted coordinator makes the difference. For members with limited internet access, a mailed letter or in-person visit may be the most reliable touchpoint.

Respecting communication preferences also means honoring language needs. A message that arrives in a patient’s preferred language, or a call that connects them directly to bilingual staff, can prevent misunderstandings that put health at risk. Warm transfers—connecting a member immediately to the right resource—can build trust, reduce frustration and prevent a lost care opportunity.

Done well, omnichannel outreach prevents people from slipping through the cracks.

Working Together With Health Plans

Health plans are essential partners in whole-person care. They bring in resources that extend beyond clinic walls; for example, transportation services, SDOH solutions and care management programs.

Partnership helps close gaps quickly. A health plan might identify members who are overdue for preventive screenings. The care team, using omnichannel outreach, can contact a member through their preferred method of communication—and even schedule the appointment during the same interaction. When plans and providers align, member interactions are easier, and members receive more support.

Health plans also strengthen the feedback loop with insights that help technology evolve in ways that reflect real-world needs. Feedback shapes how integrated platforms grow to not only meet today’s needs, but to anticipate tomorrow’s challenges.

The Future Is Connected

If overall member health and health care delivery are key objectives, whole-person care is a necessary component. Care integration—linking people, processes and technology—creates a system where members feel supported across every dimension of health.

When the perspective of care shifts to become holistic, people can be more engaged, follow through on treatment and achieve better outcomes. Providers, health plans and patients can all benefit from a connected network. Ultimately, care integration is about treating the person, not just the symptoms. And when the system connects in ways that feel seamless and supportive, everyone wins.

This blog is brought to you by MedWatchers and the views expressed are solely those of the sponsor.

The post Care Integration: Connecting People, Processes and Technology appeared first on NCQA.

Real-time Visual Notes created by Ink Factory.

As NCQA marks 35 years of advancing health care quality, the focus shifts from how far we’ve come to where we need to go next. What better place to have that conversation than the Health Innovation Summit, where industry leaders gather to discuss trending topics in health care.

NCQA Founder and President Peggy O’Kane moderated a powerhouse panel of visionary leaders—Mark McClellan of the Duke-Margolis Institute for Health Policy, J. Marc Overhage of The Overhage Group and Dana Erickson of Blue Cross Blue Shield of Minnesota—for a forward-looking discussion on the future of quality.

Challenges We Face in Reinventing Quality

The Medicare Advantage market is shrinking.

CMS projects that Medicare Advantage enrollment will fall by nearly 1 million members from 2025 to 2026—the first decline in decades. Large payers are exiting the market, leaving seniors searching for other coverage options.

Despite this trend, Erickson remains bullish on Medicare Advantage. “Beneficiaries like the experience because it provides care coordination and reduces the fragmentation that is so prevalent across our health care system,” says Erickson. “So, we believe it’s a good product and we still see a very bright future.”

Risk adjustment models are leaning towards ‘sick care’ and away from prevention.

McClellan explained that Version 28 of risk adjustment reform took out a lot of codes geared toward prevention and early stages of chronic disease that were being reported in Medicare Advantage plans. Those changes pushed us toward a fee-for-service infrastructure where downstream complications get coded more reliably than early interventions.

“Let’s not pay for the documentation, but for helping people see their risks and then change their risk trajectory,” says McClellan. “We can call it ‘paying for health.’ That’s what it really should be about.”

Technology creates opportunities, but setting priorities can be difficult.

In health care, we create programs for specific conditions, like heart disease or diabetes care, and we make progress. But the question is: How can we scale our efforts across a thousand different conditions and all of the other things we need to prioritize? That’s where we need to start thinking about systems and processes—and the data and technology that can enable large-scale change.

“Thirty years ago, the challenge was to get information into the clinician’s hands, and now we have care teams working in front of computer screens,” says Overhage. “We have data that is increasingly available and interoperable. We’re like 90% of the way there. I think in the next few years, with the right leadership and guidance, these systems will evolve in a way that makes care better for patients and makes our cost structure more sustainable.”

Value-based care has become a contested concept.

“Nobody knows what it is,” says Erickson. Because value-based care is so complex and has so many different definitions, it has been hard to implement—and that has led to disappointment within the industry. Until we reach a critical mass where we move enough of the financial incentive to pay for prevention and primary care, we’re going to get exactly what we’re paying for, which is acute care.

“Trying to do 5% of your operations one way while the other 95% is still being done another way just doesn’t work,” says Erickson. “You’re not changing the way you’re delivering care.”

Let’s Get This Train Moving

In closing, O’Kane asked each panelist to share the one thing we need to do right now to get the quality train moving in the right direction.

Alignment is key, says Overhage. “We need to continue to work on getting better alignment of the value proposition across the industry—that means patients, providers, health systems, health plans and the federal government—because the lack of alignment is going to continue to limit the progress that we can make.”

Erickson would double down on interoperability. “We have all of the technology, but we still haven’t done it right. We have to really commit to data interoperability—and that rising tide will lift all boats.”

McClellan would focus on getting data into the hands of patients. “I would like to see more groups embrace CMS efforts like ‘Kill the Clipboard’ and enable sharing of automated bulk FHIR^® data. We are already heading in that direction with prior authorizations.”

Join Us Next Year

Mark your calendar for the 2026 Health Innovation Summit, October 4-7, in Atlanta, Georgia!

The post Reinventing Quality in a New Era of Care: What Will It Take? appeared first on NCQA.