All 50 states applied for the new program, focusing their plans on workforce development, technology and data modernization, behavioral health and substance use disorder treatment, EMS and mobile care innovation, primary care access and Federally Qualified Health Center networks, facility modernization and program sustainability.ⁱⁱ

“NCQA applauds this critical investment that will help states implement bold strategies to expand access and strengthen care delivery in rural communities,” said Kristine Toppe, Vice President of State Affairs. “We’re excited to collaborate with states as they utilize the resources to advance program priorities in primary care, behavioral health and telehealth, and deliver lasting improvements in rural healthcare.”

Learn more about how funds have been distributed to states here.

What The Funds Mean for States

States will use the funding to execute their proposed plans. While each state outlined different initiatives, most focus on a combination of the following approved uses:

Care Delivery 

• Providing payments to healthcare providers for healthcare items or services.

• Helping rural communities to right-size their healthcare delivery systems by identifying needed services.

• Supporting access to treatment for substance use, opioid use disorder and behavioral health services.

Managing Chronic Disease

• Promoting evidence-based, measurable interventions—including consumer-facing, technology-driven solutions—to help prevent and manage chronic diseases.

Technology

• Providing training and technical assistance for rural hospitals to implement technologies that improve care delivery, such as remote monitoring, robotics and artificial intelligence.

• Providing technical support—including software and hardware—for significant information technology advancements to improve efficiency, cybersecurity and patient outcomes.

Alternative Payment Models

• Supporting innovative models of care, including value-based care arrangements and alternative payment models.

Workforce Expansion

• Recruiting and retaining clinicians to serve rural areas, with a minimum 5-year commitment.

How NCQA Can Help

NCQA develops standards and measures that can support state oversight and improve healthcare quality and access for rural populations.

Virtual Care Accreditation. Expanding telehealth services can help states improve access while also giving consumers tools to help prevent and manage chronic diseases. NCQA’s Virtual Care Accreditation provides a roadmap for delivering high-quality virtual primary and urgent care, fostering confidence and trust in telehealth services. Currently, Covered California encourages contracted plans to utilize network providers offering virtual care to improve access to behavioral health services in rural areas and collects information on whether those providers hold NCQA Virtual Care Accreditation.

Certified Community Behavioral Health Clinics (CCBHC) Accreditation. CCBHCs are a federally recognized model for improving access to behavioral health, substance use disorder and opioid use disorder treatment services. NCQA’s CCBHC Accreditation program provides an efficient way for states to expand this vital model for rural communities. Connecticut has utilized previous federal planning grant funds to require NCQA’s CCBHC Accreditation.

Industry Alignment. NCQA is currently hosting industry working groups focused on wellness and digital patient engagement, and the use of AI, which are yielding promising recommendations and best practices that could benefit states as they develop their rural health strategies.

“Collaboration is key as states implement their rural health strategies,” says Toppe. “NCQA looks forward to partnering with states to implement programs and measures that will drive improvement in access and quality of care for people living in rural areas.”

Contact NCQA’s Public Policy Team if you have questions or need technical assistance.

The post Rural Health Transformation Funds Awarded in All 50 States appeared first on NCQA.

“We’re listening to the market and adapting our programs to meet the needs,” says Jeni Soucie, NCQA’s Senior Manager of Product Management. “Our intent is to preserve the core elements of the program, while acknowledging that the industry has shifted and we need to focus more on certain areas, like network adequacy and population health.”

Benefits of Accreditation

For policymakers and regulators. Defines high-quality behavioral health services, helps identify organizations that provide value and streamlines oversight processes. “State Medicaid agencies need to get creative and find ways to use their limited resources to address rising behavioral health needs while other health needs remain stable,” says Soucie. “Requiring behavioral health organizations to earn NCQA Accreditation gives states confidence that their vendors meet rigorous standards for quality and access to care.”

For accredited organizations. Provides a framework for evaluating behavioral health quality, access and outcomes. Aligns with Health Plan Accreditation and supports whole-person care. “Updating the behavioral health standards creates synergies and reduces administrative burden when health plans choose to delegate behavioral health services to an NCQA-Accredited organization,” says Maria Diaz, NCQA’s Program Content Engineer.

For consumers. Helps people find the types of practitioners and care they need. “Access to care is a primary concern for people seeking behavioral health services,” says Soucie. “Our standards encourage organizations to closely monitor their networks, identify gaps and resolve them.”

What’s Changed

Beyond the name change, we’ve updated the program standards and scoring. Here is a summary of what to expect.

Network Management Standards

We reorganized standards related to Network Management into a single category and added new standards for Assessment of Network Adequacy and Delegation. As part of the network assessment, organizations must report data for prescribing and non-prescribing behavioral healthcare practitioners, making it easier for people to find the care they need.

“We also added new ways to measure distance that reflect how people receive care,” says Diaz. “We included a category for telehealth providers and added public transit as an option for calculating time and distance.”

Population Health Management Standards

We consolidated standards related to Population Health Management into a single category and added new standards for Population Health Strategy, Population Identification, Population Health Impact and Delegation. These standards help organizations demonstrate the results of population health management activities and identify opportunities for improvement.

“It is important for organizations to proactively gather information—income, race, ethnicity, language spoken—to get a better picture of the populations they serve,” says Soucie. “Many organizations are already performing some form of population health assessment, so now they can be recognized for their efforts.”

Other Changes

• Modified standards for Quality Management and Improvement and Utilization Management.
• Removed the Care Coordination category by retiring some standards and moving others into Quality Management and Improvement.
• Revised the scoring categories—Met, Partially Met, Not Met—to align with Health Plan Accreditation.
• Replaced the one-year Accreditation status with an Interim Accreditation status that focuses on policies and procedures and lasts for up to 18 months.

“NCQA’s standards provide guardrails without being prescriptive, allowing organizations to develop processes and workflows that work best for them,” says Soucie.

Learn More

• Watch our recent webinar, Navigating the Behavioral Health Landscape: Trends, Challenges and Accreditation Updates.
• Learn more about the Behavioral Health Accreditation program.
• Purchase a copy of the Behavioral Health Accreditation standards or the Behavioral Health Accreditation Survey Readiness Package in the NCQA Store.
• Take one of our online education courses: Behavioral Health Accreditation for New Customers or Behavioral Health Accreditation for Renewing Customers.

The post Behavioral Health Accreditation Promotes Accountability appeared first on NCQA.

Delegation enables health plans to leverage specialized expertise among trusted partners, strengthening oversight and advancing the quality and efficiency of care delivery. When implemented effectively, delegation promotes accuracy and operational efficiency, reduces administrative burden and creates opportunities for continuous process improvement. By aligning responsibilities with organizations best equipped to manage them, health plans can foster collaboration that supports better outcomes for members and a more sustainable health care system.

Delegation is about trust. A health plan trusts an organization to take care of its members according to a defined set of expectations. The delegate is a proxy for the health plan, because members put their trust in the health plan and expect the same level of service and attention from the delegate.

Utilization management, credentialing, population health and case management are the most commonly delegated functions. Some plans delegate network adequacy; a few delegate quality improvement.

There is inherent risk in delegation, including operational, regulatory and financial risk. When a health plan delegates a function, it retains responsibility and accountability to ensure that the delegate meets expectations. NCQA’s Health Plan Accreditation standards provide delegation oversight guidance to help plans manage risk.

Choosing a Delegate

Alignment between a health plan and its delegate can result in a positive outcome. Consider these key criteria when evaluating potential delegates.

1. Delegation requirements. Are you allowed to delegate this function? Some functions, such as a population health strategy, may not be delegated. Check the NCQA delegation standards to be sure.
2. Prior experience. How long has the delegate been performing the function? Can it provide references? View NCQA’s online report card for a list of NCQA-Accredited delegates.
3. Policies and procedures. Does the delegate have written policies and procedures? Ask to review the delegate’s policies for information about how it handles complaints, and other operational processes.
4. Systems. What systems will the delegate use to administer delegated services, and how will data flow between systems? Ask for a demonstration of the delegate’s systems and data reports.
5. Staffing. Is the delegate’s staffing up to the task? Find out if the delegate plans to subcontract any services.

Performing due diligence includes auditing your internal systems to understand how the new delegate fits into your operations.

Benefits of Working With NCQA-Accredited Delegates

Delegation is a two-way street—a collaboration that, ideally, results in a quality outcome. Although NCQA does not require organizations to work with an NCQA-Accredited delegate, there are benefits.

Benefits to the Health Plan

Oversight relief. A plan doesn’t have to oversee its delegate for certain activities.

Automatic credit. A plan receives full credit (100% scoring) for eligible elements. Review the Health Plan Accreditation Delegation and Automatic Credit appendix for a list of automatic credit opportunities across programs.

Increased efficiency. Because they specialize in a specific function, delegates often perform that function more efficiently than trying to build it in-house.

Benefits for the Delegated Entity

Better alignment. Accreditation helps you develop policies, procedures and processes that align with your customers.

Reduced burden. Accredited delegates have reduced audit oversight and faster delegation reviews.

Preferred partner. Accreditation makes your organization a more attractive contracting partner for health plans.

NCQA offers Accreditation and Certification programs for a variety of functions: Behavioral Health, Credentialing, Case Management, Population Health, Long-Term Services and Supports, Utilization Management, Wellness and Health Promotion.

Use our report cards to find NCQA-Accredited delegates and review their Accreditation status and any corrective action plans. But no matter which delegate you choose, the member experience is the top priority!

Learn More

Take our self-paced education course, NCQA Delegation Effectiveness Series.

Watch for our updated delegation toolkits—coming in early 2026!

The post The Strategic Value of Delegation for Health Plans and Delegated Entities appeared first on NCQA.

Behavioral healthcare in the U.S. faces many barriers to improved access and quality, including financial, structural and long-standing policies. But some states are exploring ways to increase access and measure improvement. NCQA has been convening with stakeholders—innovation hubs—to identify ways to drive improvement in behavioral healthcare access and outcomes.

We held state roundtable discussions on three trending topics in behavioral health—network adequacy and access; crisis care; funding and sustainability—and convened with state leaders at conferences like NatCon and the National Association of State Mental Health Program Directors Annual Meeting.

States’ Challenges

There are no easy answers to the behavioral health crisis, but standardization and measurement can help create a framework for improvement. NCQA wants to adapt our standards and measures to reflect states’ needs and priorities. Top challenges we heard include:

Surging demand. Multiple factors are intensifying the demand for care: reduced stigma, increased screening, social disconnection, the rise in gambling and other addictions.

Provider shortages. Demand is exacerbated by a shortage of behavioral health providers, especially in rural areas. Approximately 122 million people in the U.S. live in areas with mental health provider shortages.¹

Digitization of data. Behavioral health lags behind in the move to interoperable systems (primarily due to lack of funding), which complicates data sharing and coordinating with physical health care systems.

Adherence to measures. Reporting on quality measures is challenging and time-consuming, especially for rural providers. States are looking for ways to make it easier to collect data for value-based care initiatives. “If we introduce new measures, let’s make sure they work for both physical health and behavioral health,” said one roundtable participant.

Social needs screening. Many behavioral health systems are not set up to capture or receive data from other care delivery systems—data that are essential for care coordination and measurement.

Opportunities for Improvement

Despite policy and budget challenges, states are developing innovative solutions to expand behavioral health programs, support interoperability and measure quality and outcomes.

• Louisiana expanded mental health professionals eligible for Medicaid reimbursement to include provisionally licensed professional counselors, provisionally licensed marriage and family therapists and licensed master social workers as rendering providers.
• Washington State implemented community-based behavioral health enhancement funding to ensure adequate staffing for local community-based behavioral health providers.
• Some states have permanently expanded the use of telehealth for behavioral health services, which had been available on a limited basis during the pandemic.
• States are developing expanded crisis care services, including mobile crisis response and crisis care walk-in centers like Connections Emergency Behavioral Health Crisis Walk-In Center in Pennsylvania.
• Integration between physical health and behavioral health is another priority focus, with states exploring value-based care models that reward collaboration.
• Interoperability and data sharing continues to be an area of innovation. Washington State is implementing the Health Care Management and Coordination System across multiple state agencies and care settings. The system will include shared governance, data, resources and common workflows to maximize impact and efficiency.

States have many levers they can use to improve behavioral healthcare. For example, even with limited funding, states can require accreditation to help ensure that health plans and care delivery organizations meet certain standards.

How NCQA Can Help States

NCQA supports improvement in quality and access to behavioral health services in many ways:

We accredit behavioral health organizations and certified community behavioral health clinics.

Our Distinction in Behavioral Health Integration recognizes primary care organizations that excel at integrating behavioral health into their practices. NCQA recently received funding from the Health Resources and Services Administration to support Federally Qualified Health Centers and Look-Alike Health Centers that want to achieve this Distinction.

We incorporated behavioral health measures into HEDIS^® to measure and report the quality of behavioral healthcare. We updated our care continuity measures to include peer support, and we’re developing measures for network adequacy.

We engage in publicly and privately funded research on behavioral healthcare quality and access.

NCQA is creating standard, repeatable frameworks and developing outcomes measures that limit states’ administrative burden.

To learn more about NCQA’s work in behavioral health—or to join the conversation—email us at publicpolicy@ncqa.org.

Additional Resources

• Watch our recent webinar, Navigating the Behavioral Health Landscape: Trends, Challenges and Accreditation Updates.
• Listen to our Quality Matters podcast, How To Make Behavioral Healthcare Better.
• Read our white paper, Improving Accountability for Behavioral Healthcare Access.
• Visit our Behavioral Health Resource Center.

Stay in touch! Subscribe to Public Policy Notes, our quarterly policy newsletter.

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

¹https://www.csg.org/2024/10/10/mental-health-matters-addressing-behavioral-health-workforce-shortages/

The post State Innovations in Behavioral Healthcare: Challenges and Opportunities 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.

Verifiable is an NCQA-certified credentials verification organization (CVO) and software provider that supports health care organizations with large-scale credentialing operations, automated compliance monitoring and easier enrollment and licensing management.

“The purpose of credentialing—to keep patients safe and to make sure organizations remain compliant—has not changed,” says Janan Dave, Vice President of Operations at Verifiable. “But the technology enabling the process should change, so organizations can operate more efficiently at scale.”

Automation Drives Efficiency

“If you walked into a credentialing department 25 years ago, you would see file cabinets filled with manilla folders and paper,” says Dave. “Some organizations still do it that way.”

Verifiable partners with CVOs, health plans and care delivery organizations that perform credentialing in-house, to help them transition from manual and low-tech credentialing processes to automated ones. Verifiable’s customers share four common goals:

1. Make credentialing processes more efficient, and reduce manual efforts.
2. Grow provider networks, and scale operations without inflated headcount.
3. Reduce turnaround times and uphold data collection requirements to meet NCQA’s credentialing standards.
4. Create a single source of truth for self-serve insights to improve data quality and accuracy.

While efficiency is important, credentialing is also about compliance and managing the ever-present risk of sanctioned and excluded providers. “If you’re still tracking sanctions and exclusions manually, chances are, you’re going to miss something,” says Dave. “Credentialing automation can help organizations reduce risk.”

Modernizing Credentialing Processes

Verifiable has an array of solutions to help organizations meet NCQA standards—whether they perform credentialing internally, delegate it to Verifiable’s NCQA-certified CVO, or both:

• Credentialing software for organizations performing credentialing in-house or using a hybrid model of in-house and delegated services.
• CVO services for delegated credentialing arrangements.
• Provider network monitoring for sanctions and exclusions.

“Credentialing is not a one size fits all approach—organizations need flexibility based on their size, resources and strategic priorities,” says Dave. “Smaller teams and startups may prefer a sub-delegated CVO arrangement, while organizations with established processes may benefit from a hybrid or in-house model as they pursue Accreditation enabled by Verifiable’s technology.”

Benefits of NCQA Credentialing Certification

Verifiable decided to pursue NCQA Credentialing Certification to demonstrate the value of its products and services. Because credentialing is a compliance-driven process, vendors are highly scrutinized by potential customers—many are mandated by state law or contract to work with Accredited or Certified vendors.

“NCQA is the gold standard in the market when it comes to credentialing,” says Dave. “Achieving NCQA Credentialing Certification shows our organization’s commitment to compliance and reliability.”

Benefits of NCQA Credentialing Certification include:

• Demonstration of Verifiable’s commitment to providing high-quality services.
• Building trust with prospective clients.
• Reducing the audit burden for Verifiable and its customers.
• Making it easier to meet state regulatory requirements for health plans operating in states that mandate NCQA Health Plan Accreditation.

“NCQA Certification has unlocked conversations with prospective customers,” says Dave. “Organizations are hesitant to work with a vendor that hasn’t been evaluated by a respected, independent accrediting body like NCQA.”

Preparing Customers for Success

In 2024, NCQA updated its credentialing standards to reflect the modern approaches and digital verifications organizations are adopting. Verifiable used resources provided by NCQA to make sure its software and workflows remain compliant. Some best practices:

• Purchase and review new standards as soon as they are available.
• Review NCQA materials regarding changes to credentialing standards—especially when proposed changes are released for public comment.
• Check frequently asked questions on NCQA’s website a few times a month for additional guidance.
• Submit questions about the standards via My NCQA. “Responses are always timely, thoughtful and informative,” says Dave.

Verifiable also helps educate customers about changes to credentialing standards by creating easily digestible content, such as What You Need to Know About NCQA Credentialing Standards in 2025 and Beyond.

“We’re proud to have earned the NCQA seal for our credentialing services,” says Dave. “NCQA Certification gives our customers confidence that we will meet or exceed the required standards and time frames.”

Learn More

Learn more about Credentialing Accreditation and Certification.

Purchase a copy of the standards in the NCQA Store.

If you’re attending the 2025 Health Innovation Summit, October 13–15, in San Diego, CA, sign up for the pre-conference workshop, Uncovering Delegation’s Value for Your Organization.

The post Customer Success Story: How Verifiable Helps Organizations Modernize Credentialing Processes to Meet NCQA Standards appeared first on NCQA.

Utilization management involves multiple organizations, including health plans, care delivery organizations and vendors. NCQA’s Accreditation programs use a data-driven approach to help align organizations around the patient and clinician experience.

“We’re trying to address multiple pain points in the prior authorization process by putting the patient and clinician experience front and center,” says Tsveta Polhemus, NCQA’s Assistant Vice President, Product Management. “At the same time, our standards create a glidepath for health plans to ensure compliance and manage risk.”

The Utilization Management Ecosystem

Health plans base prior authorization policies on clinical evidence and benefit plan designs. Health plans might manage UM internally, or might delegate a portion of the process to another organization. Plans must perform oversight of delegates and maintain accountability for UM decisions.

• NCQA’s Health Plan Accreditation provides a UM framework, and lets plans streamline oversight if they choose to delegate UM activities to an NCQA-Accredited/Certified delegate.

Health systems bear the administrative burden of submitting prior authorizations and the financial burden of denials. Accountable care organizations that assume financial risk for a population’s overall health might need to develop their own UM programs. Health plans may also delegate UM activities to health systems.

• NCQA’s Utilization Management Accreditation helps health systems develop efficient internal processes that align with requirements in Health Plan Accreditation. NCQA review can simplify oversight if delegated functions are performed on behalf of a health plan.

Delegated entities perform UM functions on behalf of another organization, and may perform a variety of activities or specialize in a specific area such as cancer treatment or behavioral health.

• NCQA’s Utilization Management Accreditation lets delegates choose which functions they want to have Accredited/Certified, and aligns with the Health Plan Accreditation standards to reduce the burden of oversight, making them attractive contracting partners for health plans.

State and federal regulatory agencies that oversee health care programs such as Medicare and Medicaid are accountable to patients—and to taxpayers. They want to hold health plans accountable for managing care and preventing fraud, waste and abuse while also providing a positive patient and clinician experience.

• NCQA’s Health Plan Accreditation or Utilization Management Accreditation can be a roadmap for states to oversee the activities of managed care organizations and help ensure continuous quality improvement in utilization management through a data-driven approach.

Self-insured employers have similar concerns about balancing financial stewardship and patient experience, and can benefit from partnering with third-party administrators that have validated UM processes.

• NCQA’s Utilization Management Accreditation can give self-insured employers confidence that third-party administrators perform UM activities efficiently and consistently—with the data and reporting to prove it.

The Value of NCQA Accreditation

We’ve updated our utilization management standards across three Accreditation and Certification programs: Health Plan Accreditation, Utilization Management Accreditation and Certification and Behavioral Health Accreditation (formerly MBHO Accreditation).

Updates focus on data collection to establish accountability and trust. “Utilization management has mostly been viewed as an operational function,” says Polhemus. “Our new standards enable organizations to view their prior authorization processes through a quality improvement lens by collecting and reporting key metrics.”

Key updates to the standards include:

• Data Collection. Organizations must collect data—approval, denial and appeal rates, appeal overturn rate and timeliness of notifications—for each line of business. Data are often spread across an organization’s systems and departments, which creates silos. By standardizing the data collection process, organizations can gain a clearer picture of processes, and identify areas for improvement.
• Utilization Management Committee. The central point of accountability, collaboration, risk mitigation and resolution of issues uncovered through data analysis. This committee focuses on collaboration and communication among individuals and departments responsible for utilization management.
• Patient and Clinician Experience. Organizations can identify patient gaps in understanding benefits, or bottlenecks in the UM process that lead to delays in care, and take action to solve those issues.

“Our standards give organizations an opportunity to self-regulate and show how they are improving their processes,” says Polhemus. “We try to provide an accountability framework that sets them up for success.”

Learn More

Watch our webinar, Utilization Management Standards: Key Updates and Impacts.

Get the standards and guidelines in the NCQA store.

• Utilization Management Accreditation
• Health Plan Accreditation

Purchase a survey readiness resource package that includes standards and guidelines, policy fact sheet, interactive review tool for gap analysis and access to exclusive town hall meetings with NCQA experts.

• Health Plans
• Utilization Management Organizations

Find out which health plans have made a voluntary pledge to simplify prior authorization processes.

The post Breaking Down Silos in Utilization Management: A Data-Driven Approach appeared first on NCQA.

NCQA submitted a comprehensive response to the Department of Health and Human Services (HHS) Request for Information (RFI) on the Health Technology Ecosystem. Our response outlines strategic recommendations and concrete steps NCQA is taking to support a modern, interoperable and trusted digital health infrastructure.

Purpose of the Health Technology Ecosystem RFI

The Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC) are working together to strengthen the digital health ecosystem. Their goal is to promote widespread adoption of health management and care navigation tools, improve data access and exchange, and support innovations that lead to better health outcomes.

To shape future policies, CMS and ASTP/ONC are gathering feedback from a wide range of stakeholders on what’s working in digital health, what needs improvement and what barriers still exist. There are five categories of RFI questions: patients, providers, payers, technology vendors and value-based care organizations. NCQA provided comments and recommendations on applicable questions in each category.

Key Themes and Recommendations

The cross-cutting theme of NCQA’s recommendations is that CMS and ASTP/ONC should accelerate the transition to digital quality measurement to support a more interoperable and trusted digital health infrastructure. We also present solutions we are developing to address the challenges described in the RFI.

1. Empowering Patients and Caregivers

As digital tools become more central to how patients manage their health—particularly outside traditional clinical encounters—patients, caregivers and providers will need to be able to identify the tools that improve health outcomes and drive down health care costs.

NCQA’s Recommendations

• Promote third-party evaluation of digital health tools to build trust and usability.
• Develop a CMS-endorsed directory of certified tools, and incentivize integration into EHRs to support care coordination.
• Integrate disparate data sources, including pharmacy, behavioral health, social determinants and patient-generated health data (e.g., wearables), to create a more complete, person-centered view of health.

How NCQA Can Help

NCQA is developing a program that defines and evaluates high-quality digital condition management, and we plan to launch a pilot with up to 10 health care organizations this fall.

2. Supporting Providers

A significant obstacle to innovation in clinical workflows for quality measurement is reliance on outdated data standards such as the Quality Data Model (QDM) and Quality Reporting Document Architecture (QRDA). These standards were developed for electronic clinical measures, but aren’t widely used outside quality reporting, which limits interoperability and increases implementation burden.

NCQA’s Recommendations

• Retire outdated standards like QDM and QRDA and incentivize the use of HL7^® FHIR^® and CQL for quality measurement.
• Invest in tooling, technical assistance and community support to help providers and vendors adopt FHIR-based reporting and CQL-based logic.
• Align quality reporting with clinical workflows to reduce duplication and administrative burden.

How NCQA Can Help

NCQA is developing an Advanced Primary Care program that integrates digital quality measurement, care coordination and interoperability into a single, scalable solution. It draws on our experience with the PCMH Recognition program and digital HEDIS^®, ensuring compatibility with modern health IT infrastructure and enabling real-time, patient-centered performance measurement.

3. Enabling Payers

Payers need access to electronic clinical data to reduce manual reporting and promote interoperability. While TEFCA provides a framework for accessing these data, lack of clarity about data exchange fees and uncertainty about data quality creates hesitation.

NCQA’s Recommendations

• Clarify data exchange fee policies under TEFCA, and integrate data quality validation into its framework.
• Expand TEFCA’s technical capabilities to include Bulk FHIR and other scalable mechanisms for quality measurement and reporting.
• Introduce Medicare Advantage Star Ratings metrics that reward standardized, bidirectional data exchange.
• Establish an early adopters program for organizations that implement APIs ahead of regulatory timelines.

How NCQA Can Help

NCQA’s Electronic Clinical Data Systems (ECDS) reporting method for HEDIS enables the use of structured electronic clinical data from EHRs, registries and other digital sources, eliminating the need for manual chart abstraction. ECDS measures are already in use across CMS programs: the Medicaid Adult and Child Core Sets, the Marketplace Quality Rating System and the Medicare Advantage Star Ratings program. NCQA recently announced plans to transition additional HEDIS measures to ECDS reporting in the coming years.

4. Engaging Technology Vendors and Networks

Technology vendors and networks operate on the front lines of the digital transformation. To spur innovation, they need a modern, standards-based infrastructure that developers can build on—one that supports real-time data exchange, scalable quality measurement and seamless integration into clinical workflows.

NCQA’s Recommendations

• Encourage implementation of FHIR APIs and Bulk FHIR to enable real-time, scalable data exchange.
• Invest in shared infrastructure and services that developers can leverage to build scalable, standards-aligned solutions.
• Prioritize API performance, usability and real-world impact in technology certifications.
• Support a dual participation model that allows organizations to engage in both TEFCA and state/regional networks.

How NCQA Can Help

NCQA’s Digital Content Services provides a centralized, certified source of digital quality measure logic that vendors can integrate directly into their workflows, products and solutions—such as EHRs, analytics platforms and care coordination tools. Our Bulk FHIR Quality Coalition assesses the real-world feasibility of data exchange between payers and providers using HL7 FHIR APIs.

5. Advancing Value-Based Care

To successfully participate in value-based care arrangements, health care organizations must have access to timely, accurate and standardized data for evaluating performance and improving outcomes.

NCQA’s Recommendations

• Systems must support interoperable data exchange using HL7 FHIR standards and CQL for automated quality measurement.
• Value-based care models should use validated data for fair and effective performance evaluation.

How NCQA Can Help

NCQA’s HEDIS audit process helps ensure that data used to calculate performance measures are complete and accurate, and conform to rigorous specifications. Audited HEDIS data are already used in CMS Medicare Star Ratings, Medicaid managed care and commercial value-based contracts. HEDIS measures are trusted by regulators and payers, and provide a consistent benchmark for comparing performance across plans and populations.

Learn More

• Read NCQA’s full comment letter here.
• Download NCQA’s Recommendations for the Trump Administration here.

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 NCQA Responds to the HHS Health Technology Ecosystem RFI appeared first on NCQA.

Keep reading for key insights and standout moments from the discussion.

Where U.S. Health Care Falls Short—And Why

Since 2004, The Commonwealth Fund’s Mirror, Mirror report has compared health system performance across high-income countries, offering insights for U.S. improvement. Year after year, the U.S. ranks last in health outcomes, despite spending 17% of its GDP on health care—well above the 11%–12% spent by peer nations.

Research consistently shows that the U.S. health system falls short due to its poor health outcomes, wide disparities by geography and demographics, underinvestment in primary care and persistent barriers to accessing care.

What can we learn from our international peers? Dr. Betancourt points to three key drivers that set high-performing countries apart: universal coverage, strong primary care systems and robust investment in social supports. These same factors also separate the highest- and lowest-performing U.S. states. “At the end of the day, this notion that your zip code is the better predictor than your genetic code for your health outcomes is very real,” he says.

The Future is Here, and Unevenly Distributed: Reflections on Digital Innovation in Primary Care and Health Equity

Dr. Betancourt acknowledges that AI is not a silver bullet, but with thoughtful regulation and inclusive design, it has the potential to modernize care and help close long-standing gaps in our health system.

While AI carries the risk of reinforcing existing biases, he sees it as a powerful tool to standardize care, expand access and improve equity—if it is developed and implemented responsibly. In his day-to-day work with AI, Dr. Betancourt advocates an “offense-minded” approach that emphasizes innovation over fear of risk.

He believes AI and digital tools will transform primary care in the next 5–10 years by automating low-acuity care, reducing administrative burdens and enabling more proactive, guideline-based treatment. This shift would allow clinicians to focus on complex cases and lean into the human side of care: empathy, listening, trust.

Still, without equitable access to AI and digital tools, disparities could worsen. Dr. Betancourt views states as essential engines of innovation and equity, even as they face mounting pressures from potential Medicaid work requirements and slashed budgets. Now, more than ever, high-performing states show that strategic investments in digital infrastructure, primary care and social supports can drive meaningful progress.

Tough Headwinds Are Ahead, But Don’t Over-Chill

The conversation underscored mounting challenges to advancing health equity amid a shifting political and regulatory landscape, and its implications on data accessibility.

Dr. Betancourt highlighted how emerging political narratives, along with a shrinking federal data infrastructure caused by workforce cuts and de-prioritization, are driving the rollback or under-collection of race, ethnicity and health disparities data, undermining progress and weakening the foundation of equity-focused efforts.

He warned that without accurate, comprehensive data, health systems are flying blind, unable to identify or address inequities—creating what he called a chilling effect on institutions and data collection in general.

Despite the headwinds, Dr. Betancourt urged practitioners and health organizations not to “over-chill,” stating that a renewed commitment to data collection, backed by advocacy, collaboration and legal clarity, is essential to restoring trust and advancing health equity.

What’s Next for The Commonwealth Fund

Looking ahead, The Commonwealth Fund is reaffirming its core mission of providing rigorous, evidence-based analysis to policymakers and academics, while also expanding its reach to include everyday constituents. Dr. Betancourt emphasized the need to clearly communicate complex health policy issues to the public—for example, about Medicaid and the ACA. The Fund plans to deepen its engagement at the state and community levels, serving as a trusted source of accessible health information and demonstrating how policy decisions affect real lives by making data more relatable and actionable.

NCQA thanks Dr. Joseph Betancourt for sharing his time and thoughtful insights with our audience.

Visit our video gallery to watch the full Fireside Chat recording.

The post NCQA Fireside Chat: What’s Holding U.S. Health Care Back, and How We Move Forward appeared first on NCQA.

Here are some highlights and key takeaways from the forum’s second day.

Maryland’s Policy Landscape: Top Priorities

Maryland is striving to improve health equity, maternal and child health outcomes and population health. A panel of experts discussed programs on the horizon and the challenges ahead.

Key Takeaways

Programs generating excitement:

• Affordability initiatives.
• Advanced primary care and the shift from volume to value.
• Prenatal risk assessment and performance improvement project for Medicaid managed care organizations.

Areas where Maryland struggles:

• Pre-deductible coverage to tackle affordability issues—what’s the benefit of having health insurance if people can’t afford to use it?
• Health literacy, rebuilding trust in communities and connecting people to services.
• Perinatal health and racial disparities in death rates of moms and babies.

Insights from the panel:

• Public health is more important than ever—access data from public health departments, identify shared priorities and measure what matters.
• Social determinants of health continue to drive disparities. “The choices we make are the choices we have.”

Data Sharing to Address Social Needs

Addressing whole-person care requires strong connections across the health care system. Pennsylvania has built an effective statewide social needs platform to facilitate data exchange among health care and community-based organizations.

Key Takeaways

• PA Navigate is a statewide tool for social needs screening and referrals to community resources (food, shelter, transportation and more).
• The state encourages providers to screen for social needs and to work with managed care and community-based organizations to meet community needs.
• Health information organizations—regional HIEs in Pennsylvania—work with providers and managed care plans to facilitate data sharing.
• The biggest roadblock is interoperability and data standardization—statewide guidance would help.

Building a Statewide HIE: Lessons Learned

CRISP is Maryland’s state-designated HIE. We learned how it functions, data challenges the team encountered and plans for enhancement.

Key Takeaways

• CRISP leverages a master person index to link data across systems to support care delivery and coordination, population health reporting, public health and more.
• Integrating clinical, social needs and administrative data led to decreases in ED use, duplicate testing and mortality rates.
• Not all use cases require the FHIR^® data format—simpler methods of information exchange work for many.
• Clinical data quality is a challenge and requires data mapping to standardize the data.
• Future plans include exploring low-risk administrative use cases for AI.

Innovating to Address Health Disparities

Addressing disparities in care requires creativity and innovation. Our panel shared its perspective on the risks and opportunities of leveraging AI, and the impact on communities.

Key Takeaways

AI can improve community health and well-being of communities—but we can’t overlook the ethical considerations:

• Automation and the elimination of jobs at the lower end of the social economic spectrum.
• The need to upskill the workforce to correspond with digital health solutions.
• The energy infrastructure needed to store, use and analyze AI data in communities.

As we innovate, it is crucial to reflect, act intentionally and be aware of the downstream impact on communities.

Using Data to Understand and Act to Address Health Disparities

Identifying health disparities is the first step—transforming insights into action is where real impact happens. Our panel explored data-driven methods to help organizations identify and address gaps in care at the population and individual levels.

Key Takeaways

• Community-based organizations are essential partners in reducing health disparities.
• Start small with a defined population, share lessons learned through regular feedback loops, leverage technology to support referrals and outcomes measurement.
• The importance of community-based intelligence: combining data with on-the-ground feedback from community organizations and patient experiences.
• Emphasize agency and empowerment when working with underserved communities, and amplify local voices: universities, health departments, neighborhood associations, community members.

Learn More

Read more updates from the Health Quality Forum:

• Health Quality Forum Opening Remarks: “We Must Raise Our Ambitions”
• Health Quality Forum, Day 1 Wrap Up: Virtual Care, Rural Access and More

View and download the visual note boards from the event. Below is a sample.

Real-time Visual Notes created by Ink Factory.

The post Health Quality Forum, Day 2 Wrap Up: State Innovations, Social Needs Data and Reducing Disparities appeared first on NCQA.