A PCMH-recognized practice submits annual reporting to NCQA each year around its recognition anniversary, attesting to a set of criteria and supplying data on access, care management, quality and the rest. Most practices treat it as a paperwork exercise in the month before the due date. In a normal year that mostly works. This is not a normal year for patient panels, and the practices that wait until the month before will find that their empanelment data, their quality denominators and their care management lists describe patients who are no longer theirs.
Here is what is coming. Medicaid expansion adults move to six-month eligibility renewals starting with renewals due December 31, 2026, and face work requirements by January 1, 2027, with several states already enforcing them. Marketplace insurers are proposing a median 15 percent premium increase for 2027, which means plan switching in November and some coverage loss in January. Commercial deductibles reset January 1. Each of these moves patients between plans, between practices, and in and out of coverage. Each of them touches something NCQA asks you to demonstrate.
Key takeaways
- Empanelment drifts fastest during churn. Reconcile your panel against every payer attribution list you can get, quarterly, starting now, with a written rule for resolving differences.
- Freeze quality measure populations as of a date and report against the frozen list. Nightly recalculation will erase December numerator work when patients drop off in January.
- Coverage status is a risk factor. Add it, with the renewal date, to the care management registry and make an approaching renewal a trigger for outreach.
- Verify network status at the time of referral, not from last year's assumption, and log failed referrals with the reason.
Where churn shows up in the PCMH concepts
| PCMH concept | What churn does to it | What to do |
|---|---|---|
| Team-Based Care and Practice Organization | Staff roles for eligibility and coverage support are not documented | Add coverage support to the care team roles and the workflow documents |
| Knowing and Managing Your Patients | Panels include patients who moved plans or left; social needs data (including insurance status) is stale | Reconcile panels quarterly against payer attribution lists; refresh social needs screening |
| Patient-Centered Access and Continuity | Continuity percentages fall when patients are reassigned by a new plan | Track continuity by month and document the cause |
| Care Management and Support | High-risk patients lose coverage mid-plan; care plans stall | Add coverage status to the care management registry and to the risk criteria |
| Care Coordination and Care Transitions | Referrals fail because the specialist is out of the new plan's network | Verify network status at referral; log failed referrals with the reason |
| Performance Measurement and Quality Improvement | Measure denominators shrink or shift; payer gap lists disagree with the EHR | Freeze measure populations by period; document the reconciliation |
Empanelment: the number that drifts
Empanelment is the foundation of everything else in the model, and it is also the number that drifts fastest during churn. A patient who lost Medicaid in January and did not come back is still on your panel in the EHR. A patient reassigned to your practice by a new Medicare Advantage plan is on the plan's attribution list but not on yours. Payers pay for attributed patients and NCQA asks you to know who your patients are; when the two lists disagree, both money and recognition data are wrong.
Our recommendation is a quarterly reconciliation: pull the attribution or member list from each payer that provides one, compare it with your empaneled list by provider, and resolve the differences with a rule you write down. For example: a patient with no visit in 18 months and no attribution is inactivated; a newly attributed patient with no visit is flagged for outreach and assigned to a provider with capacity; a patient attributed to you by a plan but empaneled to another practice in your EHR is reviewed by the care team. Do the first one this month, before the December renewals begin, so you have a clean baseline to compare against in February.
A worked example
A four-provider family practice with about 7,200 empaneled patients ran its first reconciliation against three payer lists: a Medicare Advantage plan, a Medicaid managed care plan and a commercial ACO. The results, rounded: 640 patients on the EHR panel with no visit in 18 months and no attribution anywhere (inactivated); 310 patients attributed by a payer but not on the panel (outreach list); and 95 patients attributed to two providers in the practice at once (assigned to the one with the most recent visit). The practice's real panel was closer to 6,900, its continuity percentage rose by several points once departed patients were removed from the denominator, and its care management registry lost 40 names that belonged to patients who had moved away. None of that was visible before the reconciliation, and all of it would have appeared in annual reporting as data that did not match.
Quality measures: freeze the population
Most quality measures use a denominator defined over a measurement period, and most EHR registries recalculate the denominator every night from the current active patient list. If patients drop off the list in January, your December numerator work disappears from the report. For annual reporting and for payer quality programs, define the population as of a date, save it, and report against it. Document the method; NCQA reviewers and payer auditors both ask, and "the registry does it" is not a method.
Payer gap-in-care lists will disagree with your registry more than usual this year, because the payer's list reflects its enrollment and yours reflects your panel. Reconcile monthly, not annually, and log the reasons for each disagreement. Closing gaps while patients are still covered is also the argument for doing outreach in the fall rather than waiting for spring; we will write about that separately.
Care management: coverage as a risk factor
A patient with poorly controlled diabetes who is about to lose Medicaid is at higher risk than the same patient with stable coverage, because the insulin and the follow-up visits are about to become unaffordable. Add coverage status, and pending renewal date where you can get it, to the care management registry. Make "renewal due within 60 days" a trigger for a care manager contact whose script includes address confirmation with the state, the state's phone number and, where the patient may qualify for an exemption, an offer to have the provider document the condition. This is care management, it is documentable, and it keeps patients on your panel and in coverage.
Referrals: check the network before you send
January referral failures spike when patients switch plans and the receiving specialist is out of network. The care coordination workflow should verify network status at the time of referral, not assume last year's answer. Log referrals that fail for network reasons; the count is a useful data point for annual reporting and a useful argument in payer contracting, because a plan whose network cannot absorb your referrals is a plan you can negotiate with.
A timeline for the rest of 2026
- August: empanelment reconciliation against every payer list you can get; add coverage status to the care management registry.
- September: update team roles and workflow documents to include coverage support; train the front desk on the script.
- October: freeze quality measure populations for the reporting period; reconcile payer gap lists.
- November: referral network verification live; Marketplace open enrollment messaging out.
- December: care manager outreach to Medicaid expansion patients with renewals in the next 60 days.
- January: measure the results: panel accuracy, continuity, referral failures, care plan completion.
Questions we hear
Our annual reporting is not due until spring. Why start now?
Because the data you report in spring describes the fall and winter. If your panel and your measures drift during the December churn, the spring submission will either be inaccurate or will require weeks of reconstruction. Doing the reconciliation in August makes the spring submission a summary, not an investigation.
Does NCQA require any of this specifically?
NCQA requires that you know your patients, manage the ones at highest risk, measure your performance and improve it. It does not prescribe how you handle coverage churn. What we have described is our practical reading of how to keep those requirements true when the ground moves. Our PCMH annual review service walks practices through exactly this, and practices working toward first recognition can start with PCMH recognition and transformation.
We do not get attribution lists from most of our payers. What then?
Ask. Most Medicare Advantage plans, Medicaid managed care plans and ACOs produce them monthly or quarterly and will send them to a practice that requests them, often through the provider portal. For payers that do not, use your own visit data with the 18-month rule and document that you did. A reconciliation against two lists is better than none.
What to do this month
- Request attribution lists from every payer and ACO you participate with, and set a recurring calendar entry for each quarter.
- Write the reconciliation rule on one page and have the care team lead sign it.
- Run the first reconciliation and record the three counts: inactivated, outreach and duplicates.
- Add coverage status and renewal date fields to the care management registry.
- Put the October measure freeze date on the quality lead's calendar and decide where the frozen list will be stored.
