A recognized practice called us in February because its annual reporting date was coming up in May and the care manager had just read that the medication reconciliation threshold had gone up. She was right. NCQA's PCMH Standards and Guidelines version 11.1 took effect on January 1, 2026, and among other changes it raised the performance threshold for KM 14 and KM 15 from 80.1 percent to 90.1 percent. The practice had been comfortably clearing 80. It was not clearing 90, and it had three months of data to fix before the report.
NCQA's position is straightforward: a practice must meet the current version of the standards at all times, and recognition under an earlier version does not exempt it. That means every recognized practice reporting in 2026 is reporting against 11.1, whether or not anyone in the practice has read it. This article covers the changes that matter most for annual reporting and, more usefully, the habits that make the evidence a by-product of normal work instead of a scramble.
Key takeaways
- Version 11.1 loosened four things (daily huddles, orientation materials, the number of disparity drivers, and it spelled out care plan elements) and tightened one: medication reconciliation and medication lists now need more than 90 percent.
- The gap between 80 and 90 percent on KM 14 is rarely clinical. It is discharge notices that never become tasks and nurses who reconcile without clicking the reconciliation action.
- NCQA reviews the most recent data you can produce. A documented workflow change in March with three months at 91 percent is a strong position; backfilled clicks are not.
- Weekly habits, not a pre-report sprint, are what make annual reporting a half-day job.
What changed in version 11.1
| Criterion | Version 11.1 change | What it means day to day |
|---|---|---|
| TC 06 Individual Patient Care Meetings | Daily huddles no longer required; at least twice per week | Fewer meetings, but the ones you hold need a record |
| TC 09 Medical Home Information | Practice orientation materials no longer required; no documentation requested | One less document to maintain |
| KM 09 Diversity and Drivers of Health | Assess at least one driver of health outcome disparities (previously more) | Pick one, measure it properly, act on it |
| KM 14 and KM 15 Medication Reconciliation and Lists | Threshold raised to 90.1 percent | The hardest change; most practices need workflow work |
| CM 04 Person-Centered Care Plans | Documented at least twice per year with specified elements, shared with the patient in print or electronically | Care plan template needs every element and a date |
| QI 15 Reporting Performance | Annual sharing of one clinical quality, one cost or coordination, and one patient experience measure within the practice | A dated staff meeting agenda is evidence |
Our read of the whole package is that NCQA traded some documentation burden for a higher bar on the one criterion that most directly affects patient safety. We think that is the right trade. It is also the trade that catches practices off guard, because the relaxed items are the ones people notice and the raised threshold is the one that fails a report.
The medication reconciliation problem
KM 14 asks for medication reconciliation after care transitions for more than 90 percent of patients; KM 15 asks for an up-to-date medication list for more than 90 percent of patients. Both are measured from your own report, and both depend on the same two things: the EHR knowing a transition happened, and someone clicking the reconciliation button rather than just reviewing the list.
In the practices we work with, the gap between 80 and 90 is rarely clinical. It is usually the discharge notices that arrive by fax and never get attached to the chart, and the nurse who reconciles verbally but does not mark it. The fix is a standing task: every hospital or ED notification (from the ADT feed, the health information exchange, or the fax) creates a reconciliation task assigned to the care team within 72 hours, and the task is closed only by the reconciliation action in the EHR. Run the report weekly, not at reporting time, and post the percentage where the team can see it.
A worked example from the February call. The practice's report showed 84 percent for KM 14 on a denominator of 212 transitions in the prior six months. Thirty-four transitions were unreconciled. When the care manager pulled the 34, nineteen were hospital discharges that had arrived by fax and been scanned to the chart without creating a task, nine were ED visits the practice learned about only at the next appointment, and six were genuinely missed. Routing the fax queue to a task list fixed the first group. Enrolling in the regional health information exchange's ADT alerts, which the practice had been putting off for a year, fixed most of the second. By the time the report runs in May the practice expects to be over 92 percent, and the workflow change is documented with a date.
Care plans that meet CM 04
Version 11.1 spells out what a person-centered care plan must contain: the problem list, the medication list, clinical goals, the patient's own goals, self-management strategies, a timeframe for reassessment, and evidence that the plan was shared with the patient. It must be documented at least twice a year for patients in care management, and the sharing can be a printed copy or a copy through the portal.
The practical test is whether a stranger could read the care plan and know what the patient wants. "Improve A1c" is a clinical goal. "Be able to walk my granddaughter to school without stopping" is a patient goal, and NCQA reviewers notice the difference. We coach care managers to type the patient's words in quotation marks. It takes no extra time and it is the single most persuasive piece of evidence in the CM section.
The twice-a-year requirement is where templates help. Set the care plan reassessment date as a structured field, run a monthly report of care management patients whose plan is more than five months old, and book the follow-up before the six-month mark. Three overdue care plans out of forty is a 92 percent that reads well; fifteen out of forty is a finding.
The evidence habits
Annual reporting asks for a small set of documents, reports and examples. Practices that struggle are the ones that create the evidence in the month before the report. Practices that find it easy do these things every week:
- Every huddle gets a two-line note in a shared document: date, who attended, what was flagged. TC 06 is proven in ten seconds a day.
- The medication reconciliation and medication list reports run every Monday and are pasted into the same tracking sheet. Twelve months of data shows a trend, and a trend is far more convincing than a single number.
- Care management enrollment is reviewed monthly against the criteria in CM 01 and CM 02, with the count of patients identified, enrolled and with a current care plan.
- Quality measures for QI are pulled quarterly and the results are shared at a staff meeting whose agenda is saved with the date. That agenda is your QI 15 evidence.
- Patient experience feedback (survey results or comment cards) is summarized quarterly with one action taken. Reviewers like to see the action more than the score.
- Any new or changed workflow gets a one-page policy with a revision date. Policies are half of what NCQA asks for and they are trivial to write at the time and painful to reconstruct later.
Picking your one driver for KM 09
Version 11.1 asks for at least one driver of disparities in health outcomes, which is less than before, but it expects the one you choose to be measured and acted upon. Practices often choose language preference because the data already exists in registration. Others choose transportation, food insecurity or housing instability using a screening tool such as PRAPARE or the AHC HRSN screening questions. Whichever you choose, the evidence is a report stratified by that driver and a description of what you did about the gap it revealed.
Choose something you can act on. A practice that stratifies its diabetes control measure by preferred language and finds Spanish-speaking patients ten points behind can do something about it: interpreter scheduling, translated education materials, a bilingual care manager. A practice that stratifies by a driver it cannot influence has a report and no story, and the story is what the reviewer is reading for.
Working backward from your reporting date
Annual reporting is due on the anniversary of your recognition, and NCQA opens the reporting window in advance. Whatever your date, this is the calendar we use with practices:
| When | What to do |
|---|---|
| Five months before | Read the current criteria list for your reporting year and mark every criterion whose evidence you cannot produce today |
| Four months before | Run KM 14, KM 15 and the care plan report; if any is below threshold, change the workflow now and document the date |
| Three months before | Confirm every policy referenced in the report has a revision date within three years and matches what the practice actually does |
| Two months before | Assemble the examples: three de-identified care plans, huddle log, staff meeting agenda with QI results, patient experience summary |
| One month before | Rerun every report with the most recent data and replace the older versions |
| Reporting month | Upload, then read the submission as a stranger would |
Questions we hear
Our recognition was granted under version 8 standards. Do we really have to change anything?
Yes. Annual reporting is against the current version. You do not re-apply, but the criteria you report on and the thresholds you must meet are the 11.1 versions. Read the criteria that changed and check your reports against them at least three months before your reporting date.
We are at 84 percent on medication reconciliation with two months to go. What do we do?
Fix the workflow now and report honestly. NCQA looks at the most recent data you can produce, so a March through May run at 91 percent with a documented workflow change is a strong position. Backfilling clicks on old encounters is not.
Is there a way to reduce the annual reporting effort?
The habits above reduce it more than anything else. If you want an outside review of your evidence before submission, our PCMH annual review service reads your reports against the current standards, and our PCMH recognition work builds the weekly routine into the practice from the start.
What to do this month
- Run the KM 14 and KM 15 reports for the last six months and write down the percentages and the denominators.
- Pull the unreconciled transitions and sort them by how the practice learned of the transition: fax, ADT alert, patient report, or not at all.
- Route every discharge and ED notification into a task that closes only on the reconciliation action, and date the policy change.
- Open three current care plans and check them against the CM 04 element list, including the patient's own goal and evidence of sharing.
- Start the huddle log and the Monday report habit this week, even if your reporting date is months away.
