Practices with NCQA Patient-Centered Medical Home recognition report once a year to keep it. The report is not a re-survey; it is a check-in with attestations, a set of data submissions and a rotating selection of criteria for which the practice must show evidence. The practices we work with fall into two groups: those that treat it as a June-to-due-date project and those that treat it as a two-week scramble. The first group keeps recognition without drama. The second group calls us in a panic.
June is also a good time to look ahead, because NCQA published proposed updates to the 2027 PCMH standards for public comment this spring, with comments closing on April 17, 2026. The proposals concentrate on the Care Management concept, and they are worth understanding now even though the final version is not yet out.
Key takeaways
- Look up your due date and the criteria NCQA selected for evidence in Q-PASS now; you cannot gather evidence for criteria you have not read.
- The care management population report and care plan sample are the items most often found deficient and the slowest to assemble.
- Logs that were not kept in the spring cannot be reconstructed. Check same-day access, after-hours advice and referral tracking now.
- NCQA's 2027 proposals change three core Care Management criteria and fold the CM 07 elective into CM 04.
- Do not relax your CM 02 population until the final 2027 language is published.
What annual reporting asks for
The program has six concepts (Team-Based Care, Knowing and Managing Your Patients, Patient-Centered Access and Continuity, Care Management and Support, Care Coordination and Care Transitions, Performance Measurement and Quality Improvement), 40 core criteria and a set of electives worth one, two or four credits. Recognition requires all core criteria plus 25 elective credits across five of the six concepts. Annual reporting asks the practice to attest that it still meets the core criteria and its chosen electives, and to submit evidence for a subset that NCQA selects, along with performance data on clinical quality, resource use and patient experience measures.
The June check
| Item | Why start in June |
|---|---|
| Confirm your reporting due date and the evidence request in Q-PASS | The selected criteria differ each year; you cannot gather evidence for criteria you have not looked up |
| Pull 12 months of clinical quality measures with numerators and denominators | Reports often need EHR vendor help, and vendors take weeks |
| Pull the care management population report (CM 02) and a care plan sample (CM 04) | These are the criteria most often cited as deficient; the sample takes time to assemble |
| Check that your patient experience survey ran and results exist | A survey that did not run cannot be run retroactively |
| Review same-day access data and after-hours clinical advice logs (AC criteria) | Logs that nobody kept in the spring cannot be reconstructed |
| Confirm the referral tracking report still runs and shows closed loops (CC criteria) | Report definitions drift after EHR upgrades |
| Check for staff, site or ownership changes that require notification | Unreported changes are a common reason recognition is questioned |
Where practices fall short
Three findings recur. First, the care management population is too small or undocumented: the practice identifies patients informally, and the report of who is in care management and why does not exist. Second, care plans are in the chart but not in the form the criterion requires; a problem list with a medication reconciliation is not a person-centered care plan with patient goals. Third, quality improvement activities happened but were not written up as a PDSA cycle with a baseline, an intervention and a re-measurement. None of these are hard to fix in June. All of them are hard to fix the week the report is due.
A worked example: rebuilding the care management evidence
Take a three-site family practice with about 9,000 active patients that identified patients for care management by "the ones the nurse knows." Its Q-PASS evidence request for 2026 includes CM 02 and CM 04. In June it has no population report and 14 care plans that are really medication lists. Here is what the summer looks like.
| Week | Work | Output |
|---|---|---|
| June, weeks 1 to 2 | Define the identification categories the practice uses (behavioral health, high cost or utilization, poorly controlled conditions, social needs, referrals from staff or patients) and run EHR queries for each | A candidate list of about 260 patients with the category that qualified each one |
| June, weeks 3 to 4 | Care team reviews the list and confirms who is actively in care management | A monitored population of 95 patients, above the 30-patient minimum, with the reason recorded |
| July | Rebuild the care plan template: problem list, medication list, expected outcomes, patient goals in the patient's words, barriers, and a review date | A template that meets CM 04 as written |
| August | Complete plans for the sample NCQA will review, at scheduled visits or outreach calls | Care plans for the required sample size, dated and shared with patients |
| September | Write the process document: how patients are identified, monitored and discharged from care management | The policy NCQA expects to see alongside the report |
Four months, roughly two hours a week from a care manager and one report from the EHR vendor. Started in June, it is a routine project. Started in October for a November due date, it is the panic call.
What NCQA proposed for 2027
The public comment document proposed changes to three core criteria and the retirement of one elective, all in Care Management and Support, for evaluations beginning January 1, 2027:
- CM 01 (Identifying Patients for Care Management). Pediatric-specific sites would be required to use at least two of the identification categories rather than three, reflecting that pediatric panels rarely have the same range of high-cost or complex-condition patients.
- CM 02 (Monitoring Patients for Care Management). The minimum care management population would become 30 patients or 1 percent of the site's total patient population, whichever is smaller. For a site with fewer than 3,000 patients that means fewer than 30; for larger sites the 30-patient floor stays.
- CM 04 (Person-Centered Care Plans). The criterion would refer to patients "engaged in" care management rather than "identified for" it, clarifying that plans are expected for patients actually receiving the service, and the care plan elements would be restated: a problem list, a medication list, expected clinical outcomes, patient treatment goals (SMART goals accepted), and a date or timeframe for review.
- CM 07 (Patient Barriers to Goals). This elective would be retired, with its requirement to address barriers folded into core criterion CM 04.
NCQA's stated reasoning is that practices found the current criteria hard to apply across different populations and case mixes, that the prescribed goal types were unclear and poorly matched to patients identified for behavioral health or social needs, and that small practices and satellite sites could not reach the 30-patient minimum without a burdensome exception process. We agree with the observations. The 1 percent alternative will help small rural sites that have been recognized for years and dread CM 02 every cycle. Folding barriers into the core care plan is the right idea and will add work for practices that skipped CM 07 as an elective.
These are proposals. NCQA typically publishes final standards updates in the summer for the following year, and the proposal memo says the changes would apply to evaluations beginning January 1, 2027. If you rely on CM 07 for elective credits, plan a replacement now; if you are a small site, do not relax your CM 02 population until the final language is published.
Timeline for the rest of 2026
- June: confirm due date, pull evidence list, request EHR reports.
- July and August: assemble evidence, fix gaps (care plan format, QI write-ups), run the patient experience survey if it has not run.
- Six weeks before the due date: internal review against each selected criterion, with the same rigor an NCQA reviewer applies.
- Two weeks before: upload, attest, submit. Leave a margin for Q-PASS questions.
- After NCQA publishes the final 2027 standards: map the changes to your electives and update your care management process document.
Our PCMH annual review service runs this timeline with the practice, and practices pursuing first-time recognition can read about PCMH recognition and transformation. Rates are on the pricing page.
Questions we hear
Do we have to meet the 2027 changes in our 2026 annual report?
No. Annual reports are evaluated against the standards in effect for your reporting year. The 2027 proposals apply to evaluations beginning January 1, 2027, once finalized.
What happens if we miss the annual reporting deadline?
NCQA's policies provide a process for late submissions, but recognition can lapse, and payers that pay a PCMH differential will stop paying it when the status changes. Treat the date as firm.
Our EHR vendor says the quality measure report will take six weeks. Is that normal?
Unfortunately, yes, which is why the request goes in during June. Ask for the numerator and denominator definitions in writing at the same time, so you can check the report when it arrives rather than discovering in October that it counted the wrong population.
What to do this month
- Log in to Q-PASS, confirm the due date and download the evidence request.
- Request the 12-month clinical quality measure report from the EHR vendor, with definitions.
- Run the care management population query and count who is actively monitored.
- Pull five care plans and compare them to the CM 04 elements. Fix the template if they fall short.
- Confirm the patient experience survey has run or is scheduled.
- Read NCQA's 2027 proposal memo and list which of your electives it touches.
