Total Care for General Population (TCGP)

Value Based Payment Quality Measure Set
Measurement Year 2026

  • Measure Set is also available in Portable Document Format (PDF)

January 2026                     NYS Medicaid Value Based Payment

INTRODUCTION

The Measurement Year (MY) 2026 Total Care for General Population (TCGP) Quality Measure Set was created in collaboration with the Primary Care (Physical Health), Maternity Care, Behavioral Health/Health and Recovery Plans (HARP), People Living with HIV/AIDs, and Children's Clinical Advisory Groups (CAGs), as well as the New York State Department of Health (the Department) CAG Strategy team. The goal of this measure set is to align with measures put forth in the NYS Quality Assurance Reporting Requirements (QARR), the Healthcare Effectiveness Data and Information Set® (HEDIS)1 Technical Specifications for Health Plans, the Centers for Medicare & Medicaid Services (CMS) Core measure set, the Merit-based Incentive Payment System (MIPS), and the Medicaid Managed Care (MMC) Quality Incentive program, where applicable. The measure set is designed to encourage providers to meet high standards of patient-centered clinical care and coordination across multiple care settings.

MEASURE SELECTION AND FEASIBILITY

To encourage a broader diversity of quality measures appropriate to member populations being served by a TCGP arrangement, the Department grouped all measures in the TCGP measure set into domains and added the following requirement to the Value Based Payment (VBP) Roadmap2:

Managed Care Organizations (MCOs) that execute a TCGP VBP arrangement must base shared savings and risk distribution on quality measures that include at least one Category 1 Pay-for-Performance (P4P)measure from each of the following domains:

  • Primary Care
  • Mental Health
  • Substance Use Disorder
  • HIV/AIDS
  • Maternity
  • Children's

TCGP VBP arrangements that exclude pregnant women, children, or persons living with HIV/AIDS are not required to include quality measures from these respective quality measure set domains. However, TCGP arrangements that carve out HARP members are still required to include quality measures from the primary care, mental health, and substance use disorder quality measure domains, in addition to the maternity, children, and HIV/AIDS domains, if these latter populations are included.

HEALTH EQUITY VBP ARRANGEMENT REQUIREMENTS

In MY2022, NCQA added race and ethnicity stratification (RES) to several HEDIS measures to help promote transparency in health plan performance. For complete details, refer to the NCQA's Health Equity webpage: Data, Measurement and Equity. To align with this initiative, in July 2022, NYS required payers and providers to incorporate race and ethnicity measure stratification in VBP arrangements. Please refer to the following section for the VBP contracting stratification specifications.

Stratification Specifications:

Payers are required to include at least one of the NCQA RES measures in all level 1 or higher VBP contracts and stratify results by race and ethnicity categories as outlined in the NCQA Race and Ethnicity Stratification Resource Guide, Stratified Measure list.3

Stratification Requirements:

  1. Arrangement appropriate measure(s) from the MY2026 TCGP Quality Measure Set should be selected for stratification of race and ethnicity provided the two groups approve on the contracting elements around other performance of the measure.
  2. Payers are required to include the following details in the Provider Contract Statement and Certification form (DOH-4255)4 and Contract language:
    1. Indicate what measure(s) are included for race and ethnicity stratification.
    2. Indicate how the stratified measure results for applicable measures will be shared with the VBP contractor.
  3. Plans are required to include the race and ethnicity data when submitting to NYS. Race and ethnicity data will be collected via the Quality Assurance Reporting Requirements (QARR) Patient Level Detail (PLD) file. This will allow the Department to stratify measure performance by race and ethnicity categories for applicable performance measures at the VBP contract and VBP Contractor levels.

All new contracts must meet this requirement to be approved by the Department. All other existing contracts were to be updated/amended at the end of the contract's current measurement period and before the contract's next measurement period began.

MEASURE CLASSIFICATION

In previous years, measures have been designated by the Department as Category 1, 2, or 3 with associated recommendations for implementation and testing for future use in VBP Arrangements. The current TCGP Measure Set only includes Category 1 Measures. These measures are intended to be used to determine the amount of shared savings for which VBP contractors are eligible.5 The TCGP Measure Set consists of P4P and P4R measures, as defined below.

  • P4P measures are intended to be used to determine shared savings amounts for which VBP Contractors are eligible. In other words, these are the measures on which payments in VBP contracts may be based. Measure performance can be considered in both the determination of the target budget and in the calculation of shared savings for VBP Contractors.
  • P4R measures are intended to be used by the MCOs to incentivize VBP Contractors to report data to monitor the quality of care delivered to members under a VBP contract. Incentives for reporting should be based on timeliness, accuracy, and completeness of data.

MY2026 TCGP QUALITY MEASURE SET

The measures provided on the following pages are recommendations for MY2026. Note that measure classification is a Department recommendation, and implementation is to be determined between the MCO and VBP Contractor. Measure sets and classifications are considered dynamic and will be reviewed annually. Updates will include measure additions, deletions, recategorizations, and/or reclassifications from P4R to P4P or vice versa, based on experience with measure implementation in the prior year. Please see Appendix A for a full list of these changes for MY2026.

The table below displays the MY2026 TCGP Quality Measure Set, arranged alphabetically within domains and includes the measure title, the measure steward and the Department P4P or P4R classification.

TCGP Measure Steward Class
2026 TCGP Primary Care Domain
Adult Immunization Status - Electronic (AIS-E) NCQA P4P
Breast Cancer Screening - Electronic (BCS-E) NCQA P4P
Cervical Cancer Screening (CCS-E) NCQA P4P
Chlamydia Screening (CHL) NCQA P4P
Colorectal Cancer Screening - Electronic (COL-E) NCQA P4P
Controlling High Blood Pressure (CBP) NCQA P4P
COVID-19 Immunization Measure (CVS) NYS P4P
Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) NCQA P4R
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) NCQA P4P
Eye Exam for Patients With Diabetes (EED) NCQA P4P
Glycemic Status Assessment for Patients With Diabetes (GSD) NCQA P4P
Initiation and Engagement of Substance Use Disorder Treatment (IET) NCQA P4P
Kidney Health Evaluation for Patients With Diabetes (KED) NCQA P4P
Social Need Screening and Intervention (SNS-E) NCQA P4P
2026 TCGP Mental Health Domain
Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) CMS P4P
Depression Remission or Response for Adolescents and Adults (DRR-E) NCQA P4P
Follow-Up After Emergency Department Visit for Mental Illness (FUM) NCQA P4P
Follow-up After Hospitalization for Mental Illness (FUH) NCQA P4P
Potentially Preventable Mental Health Related Readmission Rate 30 Days (PPR-MH) NYS P4P
2026 TCGP Substance Use Domain
Follow–Up After Emergency Department Visit for Substance Use (FUA) NCQA P4P
Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) NCQA P4P
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence (POD-N) NYS P4P
Pharmacotherapy for Opioid Use Disorder (POD) NCQA P4P
2026 TCGP HIV/AIDS Domain
HIV Viral Load Suppression (VLS) NYS P4P
2026 TCGP Maternity Domain
Prenatal & Postpartum Care (PPC) NCQA P4P
Prenatal Immunization Status (PRS-E) NCQA P4P
2026 TCGP Children's Domain
Child and Adolescent Well-Care Visits (WCV) NCQA P4P
Childhood Immunization Status – Combination 3 (CIS-E) NCQA P4P
Developmental Screening in the First Three Years of Life (DEV-N) OHSU /NYS P4P
Immunizations for Adolescents – Combination 2 (IMA-E) NCQA P4P
Oral Evaluation, Dental Services (OED) NCQA P4R
Topical Fluoride for Children (TFC) NCQA P4P
Well-Child Visits in the First 30 Months of Life (W30) NCQA P4P

Appendix A

The table below identifies the changes to the measures for the MY2026 TCGP Quality Measure Set.

Measure Changes from MY2025 to MY2026

Measure Name Change Rationale for Change
Adult Immunization Status - (AIS-E) Measure Revised for MY2026 Added COVID indicator
Asthma Medication Ratio (AMR) Removed Measure retired from HEDIS for MY2026
Topical Fluoride for Children (TFC) Classification Change P4R to P4P

*ECDS: HEDIS Electronic Clinical Data Systems

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1. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).1
2. New York State Roadmap for Medicaid Payment Reform website 2
3. NCQA Race and Ethnicity Stratification Resource Guide, Measurement Year 2026, Page 5 (Link) 3
4. DOH 4255 has been updated, Section C 2e, to include a Quality Measure Race and Ethnicity Stratification section 4
5. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value-Based Payment: Annual Update, May 2022. 5