HPR Fundamentals
What does HPR stand for in NCQA’s rating system?
Health Plan Ratings
What is the name of the system used to submit HEDIS and CAHPS data to NCQA?
Interactive Data Submission System (IDSS)
What is the maximum number of stars a plan can receive in HPR?
5 stars
What are the three types of measures used in HPR scoring?
HEDIS, CAHPS, and Accreditation
Name one behavioral health measure required for Medicaid HPR.
Follow-Up After Hospitalization for Mental Illness (FUH)
Which lines of business are included in HPR ratings?
Medicaid, Medicare, Commercial, and Off-Exchange
When is the typical deadline for Plan Confirmation in the HPR process?
Early May
How are Accreditation bonus points applied in HPR scoring?
Added to the weighted average score before rounding (Full accreditation: 0.5 pt, interim 0.15 pts)
What do these 5 measures have in common - BPC, CBP, GSD, IMA, CIS
What CAHPS survey options can Medicaid plans choose from?
Adult CAHPS or Child CAHPS (Child CCC or General)
What is the rating scale used in HPR?
0 to 5 stars, in 0.5-point increments
What is the purpose of the “Plan Confirmation” step in HPR?
To verify plan details like name, accreditation status, and CAHPS selection
What is the rounding rule for a final HPR score of 3.74?
Rounded to 3.5 stars
What is the weight of patient experience measures in HPR?
1.5
What happens if a Medicaid plan misaligns its CAHPS component selection?
It receives “NR” (Not Reported) and a score of 0 for CAHPS
What are the three composite domains used in HPR scoring?
Patient Experience, Prevention and Equity, and Treatment
When are final HPR ratings publicly released each year?
Around September 15
What does NCQA use to determine individual measure ratings?
National percentile benchmarks (10th, 33.33rd, 66.67th, 90th)
What is the minimum denominator required for CAHPS survey measures to be scored?
100 responses
What is the minimum enrollment for a Medicaid plan to avoid the “Low Enrollment” display code?
15,000 members
What is the minimum percentage of scorable measures required for a plan to receive an HPR rating?
At least 50% of required measures by weight
What happens during the HPR projected ratings review period?
Plans validate projected ratings and confirm accuracy within 10 business days
What happens if a plan does not have a numerical rating in all three composite domains?
It receives “Partial Data Reported” or “Insufficient Data”
What is the weight of the Race/Ethnicity Diversity of Membership (RDM) measure?
1.0
What is the scoring rule for the Language Diversity of Membership (LDM) measure?
Score of 5 if “Unknown” language is <80%; otherwise, score of 0