Why Risk Adjustment Matters

Individual health outcomes are shaped by underlying risk factors, which can distort comparisons between health plans if we do not properly account for them. Risk adjustment ensures that performance comparisons reflect differences in care delivery, not differences in the distribution of members’ health status (i.e., case mix). Risk adjustment allows for “apples to apples” comparison between health plans.

Essentially, risk adjustment asks: How would performance compare if all organizations had the same patient population?

There are multiple risk adjustment methods. NCQA uses statistical models for our HEDIS measures to predict outcomes by considering factors such as:

• Age and gender.
• Comorbidities.
• Procedure subtypes.
• Discharge conditions.

These models are the source of the risk weights found in NCQA’s RAU tables. Health plans use the tables to calculate an expected event rate, which is then compared to the observed event rate using an observed-to-expected ratio. The observed-to-expected ratio reflects risk-adjusted performance and shows whether a plan performed better or worse than expected based on its unique case mix.

When interpreting measure results, calibrate the ratio by dividing the individual organization ratio or national percentiles by the national average ratio. A calibrated ratio of <1.0 indicates better than expected performance, while a calibrated ratio of >1.0 indicates worse than expected performance.

For example, for the Plan All-Cause Readmission measure, a plan with a calibrated ratio of 0.8 may be successful at achieving fewer readmissions than expected, given its patient population.

New for MY 2026: Four Risk‑Adjusted Utilization Measures

NCQA has added four new RAU measures for HEDIS MY 2026:

• Acute Hospitalizations Following Outpatient Orthopedic Surgery (HFO).
• Acute Hospitalizations Following Outpatient General Surgery (HFG).
• Acute Hospitalizations Following Outpatient Colonoscopy (HFC).
• Acute Hospitalizations Following Outpatient Urologic Surgery (HFU).

These measures evaluate the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations (inpatient and observation stays) for any diagnosis within 15 days of an outpatient surgical procedure, for persons 65 years of age and older. Each measure focuses on a targeted outpatient surgical procedure.

Risk-Adjusted Tables Overview

NCQA publishes two types of RAU tables:

• Shared Tables: Provides the logic for mapping diagnosis codes into clinical categories and applies across risk-adjusted measures.
• Measure-Specific Tables: Provides measure-specific risk weights used to calculate expected values. There are 10 measure-specific tables—one for each risk-adjusted measure. Some measures report multiple product lines and each product line has its own set of weights.

Note: Measures in the Medicare product line have different sets of risk weights for enrollees ages 65+ and enrollees under 65.

Updates to the Risk-Adjusted Utilization Tables

The HEDIS MY 2026 RAU Shared Tables introduce a new table.

New: Table Proc-Mapping

A new tab titled “Table Proc-Mapping” was added to the Shared Table to support identification of procedure subtypes used in risk adjustment weights for three of the four new RAU measures (HFG, HFO and HFU). This table maps CPT codes to Clinical Classifications Software (CCS) procedure subtypes.

The risk adjustment model identifies all CPT codes associated with each outpatient surgery episode date. Each CPT code is assigned to a procedure subtype using Table Proc-Mapping. Only CPT codes in the denominator value set are included when assigning CPT codes to procedure subtypes. For example, in the HFU measure, only map the CPT codes in the Urologic Surgery Value Set. All associated CCS codes are captured for each episode. CPT codes that cannot be mapped to a CCS category are excluded.

Example

An outpatient surgery episode includes CPT codes 10160, 11762 and 15934:

• CPT 10160 maps to CCS 170 (Excision of skin lesion).
• CPT 11762 maps to CCS 175 (Other OR therapeutic procedures on skin/breast).
• CPT 15934 maps to CCS 170 (Excision of skin lesion).

Final procedure subtypes: CCS 170 and CCS 175 (with CCS 170 counted once). These CCS codes are used as risk weight variables in the risk adjustment calculation.

Note: The HFC measure currently does not assign CCS categories because colonoscopies only fall under one CCS category.

Conclusion

The MY 2026 Risk Adjusted Utilization Tables introduce new measures, enhanced mapping tools and substantive model updates designed to improve fairness and accuracy in health plan comparisons. By refining how underlying patient risk is captured, NCQA strengthens the reliability of HEDIS reporting—ensuring results reflect clinical performance, not population differences.

If you have any questions regarding the measures or ordering the RAU tables, submit a question to NCQA staff through My NCQA.

Frequently Asked Questions (FAQs)

Why did the risk weights change in MY 2024?

Risk weights are refreshed every 3–4 years to keep pace with changes in healthcare data patterns. The risk adjustment models are generated from past cross-sections of utilization data and are used to predict outcomes in future measurement years. As utilization patterns, coding practices, care management trends and population characteristics change, older models become less predictive.

NCQA also periodically re-estimates the models based on more contemporary data, allowing the variables included in the models and their associated weights to reflect changes to underlying relationships between the risk adjustment variables (e.g., age, gender, comorbidities as recorded in claims) and the outcomes (e.g., hospital readmissions). Re-estimating the models supports both measure reliability and validity.

NCQA derives many of the clinical conditions used in risk models from the CMS Hierarchical Condition Category (HCC) risk adjustment methodology. These risk models are also updated regularly. The Shared Tables include a tab summarizing changes for that year.

When the weights and models are re-estimated, new data is incorporated, which can reveal changes in the relationships among different variables.

Why might a condition that appears to be more severe be assigned a lower HCC risk weight than a related condition?

Several statistical and population-based factors can cause this:

• Multicollinearity (or sometimes just collinearity): There is a correlation among HCCs; people with a “severe” level condition might be more likely than people with a “moderate” level of the same condition to have other HCCs that absorb some of the excess risk associated with the condition.
• Outlier exclusion: People with a severe level of a condition may be considerably more likely to have enough hospitalizations to reach the outlier threshold and thus be excluded from the denominator entirely.
• Compositional effect: Those who remain could be unusually unlikely to experience an event, which can be thought of as a compositional effect.

Any of these dynamics could result in the “moderate” or “mild” level of a condition having a higher risk weight than the “severe” level of the condition.

What models are used for the RAU measures?

NCQA employs statistical prediction models to estimate expected event rates for each measure outcome. To obtain the risk weights, statistical relationships between the potential risk adjustors and the outcomes are assessed using generalized linear models:

• Logistic regression is used to estimate model coefficients and values are summed across a plan population for measures with outcomes based on proportions (i.e., each denominator unit can only have one instance of the outcome).
• Logistic + Poisson regressions are used to estimate model coefficients for measures with outcomes based on rates (i.e., each denominator unit can have many instances of the outcome).

The expected rates derived from the models are compared to observed performance to generate risk-adjusted performance assessments (observed-to-expected ratios). NCQA fits these separately for each utilization measure to produce risk weights.

Can you give more details about the statistical models you use?

For the Plan All-Cause Readmissions (PCR) measure and the Hospitalization Following Discharge From a Skilled Nursing Facility (HFS) measure, NCQA uses penalized logistic regression to predict whether an index hospitalization will result in a readmission.

For the other risk-adjusted measures, NCQA uses penalized logistic regression to predict whether the denominator member would have any numerator event (versus none) and then penalized Poisson regression to predict the number of numerator events, among those who have at least one.

Each measure accounts for a combination of risk weight variables:

• Age and gender.
• Comorbidities (HCCs).
• Procedure type.
• Discharge conditions.
• Surgeries.
• Observation stay discharge.
• COVID discharge.
• Medication.

Note: Not every measure or product line has every type of variable.

In addition, the risk-adjustment models consider interactions using the “combination” HCCs, which are specified in the Shared Tables, as some combinations present a greater amount of risk when observed together.

The models address effect modification by estimating separate sets of risk weights for different populations (e.g., Medicaid, Medicare age 18–64, Medicare age 65+).

Example

Considering the PCR measure, the model specifies that the log odds of a hospital readmission within 30 days of an index hospital discharge are a linear combination of a set of indicators:

• Age and gender combinations (of which each denominator unit belongs to exactly one; all combinations are shown in the risk weight tables).
• Comorbidities observed via diagnosis codes in claims in the year prior to the index hospital discharge (shown in the Shared Tables with the HCC labels).
• Conditions primarily associated with the index hospital stay itself (these have the “discharge CC” label in the Shared Tables and/or risk weight tables).
• Whether the index hospital stay was associated with a surgery.
• Whether the index hospital stay was an observation stay.
• Whether the index hospital stay had a principal discharge diagnosis of COVID-19 (for Medicare 65+ only).

Not all possible predictors are in each population’s set of risk weights, which means that for some populations, some of the risk weights are zero.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post HEDIS® Risk-Adjusted Utilization Tables: New Measures, Shared Table Updates and FAQs appeared first on NCQA.

Colorectal cancer represents approximately 8% of all new cancer cases; it is the third most commonly diagnosed cancer in the United States and the leading cause of cancer deaths in men under 50.¹ Routine screening—through colonoscopy, stool-based testing or other methods—can detect precancerous polyps that can be removed before they develop into a later-stage cancer.

“Many individuals with a positive screening through a stool-based test do not receive the necessary follow-up care, such as a colonoscopy,” says Brenna Lin, NCQA’s Applied Research Scientist. “Ensuring that abnormal screening results are followed by timely diagnostic care is essential to achieving the full benefit of screening. The proposed HEDIS measure is designed to address this quality gap.”

Progress Over the Past Year

NCQA continues its partnership with the Council of Medical Specialty Societies and the American Gastroenterological Association to develop a new HEDIS measure to improve follow-up care for patients who receive positive colorectal cancer stool-based test screening results. The project is funded by the Centers for Disease Control and Prevention.

We advanced the measure through several major development steps:

• Completed a comprehensive review of clinical guidelines and evidence to ensure alignment with current standards.
• Presented the draft measure to three NCQA advisory panels. Their guidance informed refinements to the measure’s intent, specifications and feasibility.
• Conducted field-testing with three partner organizations to assess feasibility, evaluate performance using real-world data and guide updates to measure specifications.

Now Open for Public Comment

The proposed HEDIS measure, Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test, is posted for public comment through March 13. NCQA welcomes feedback from all individuals and organizations who wish to share their perspectives. Public comment is a vital part of the measure development process and helps ensure that new measures are scientifically sound, meaningful and feasible to implement.

Visit our public comment webpage to learn more or to submit your comments.

Acknowledgements

The NCQA Healthcare Effectiveness Data and Information Set (HEDIS) Measures for Colorectal Cancer Screening project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award to the Council of Medical Specialty Societies (CMSS) totaling $1,563,853 with 100 percent funded by CDC/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor endorsement by, CDC/HHS or the U.S. Government.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

¹National Cancer Institute, 2023.

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You can use this report to:

• Learn more about each quality measure, how it is defined and why it matters.
• Access national averages and historical trends for over 90 measures of clinical quality and patient satisfaction.
• Compare performance across different products, like Commercial, Medicare and Medicaid.

We will add data for MY 2025 in February 2027, or you can get it sooner through NCQA’s Quality Compass^®.

How to Access the State of Health Care Quality Report

The report is available through this link. You can also find a link to the report on the HEDIS Measures and Technical Resources web page.

• We recommend that you bookmark the page for easy access.
• You’ll need to enter your contact information on a measure page to access national averages for all measures. (You only need to do this once, but if you clear your browsing data, you might need to enter your information again.)
• The information in the report is for internal use only and may not be redistributed or used for commercial purposes.

Watch this video to learn how to access the report.

Better Benchmarking With Quality Compass

NCQA’s Quality Compass provides access to health plan performance, including HEDIS^® and CAHPS^® benchmarks to identify areas for improvement. It features benchmarks at the national, state and regional levels as well as plan-specific results for competitor analysis.

Release dates for Quality Compass 2026 (MY 2025 Data) vary by product line: Commercial on July 31; Medicaid on August 28; Medicare on October 30; Exchange on November 20.

Learn More

• Read our blog Improving HEDIS Performance Through Benchmarking.
• Visit the State of Health Care Quality web page.
• Use NCQA’s Health Plan Ratings to review and compare health plan performance.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Quality Compass^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post New Data Added to the State of Health Care Quality Report appeared first on NCQA.

NCQA seeks public feedback on proposed new HEDIS^® measures and changes to existing ones. Reviewers are asked to submit comments to NCQA in writing via the Public Comment website by 5:00 p.m. (ET), Friday, March 13. NCQA acknowledges that the healthcare policy environment is rapidly evolving, and we will consider all comments received, as well as any policy changes, as we prepare the final versions of these measures.

NCQA seeks comments on the following:

• Seven new HEDIS measures.
• Revisions to three existing HEDIS measures.

About HEDIS and Public Comment

HEDIS measures are based on scientific evidence. When new evidence emerges, NCQA reviews the measures to determine if changes may be needed. NCQA convenes multi-stakeholder advisory panels—including independent scientists, clinicians, health plans, purchasers, government and consumer groups—to ensure that measures meet and balance the high standards of relevance, scientific soundness and feasibility.

An important part of developing and updating HEDIS is gathering input from the public. NCQA reviews all comments received during the public comment period, and discusses results with stakeholder advisors.

HEDIS measures do not constitute clinical practice guidelines and should not be used to determine insurance or coverage.

Proposed New HEDIS Measures

Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test: Assesses the percentage of persons 45-85 years of age who received a colonoscopy for a positive colorectal cancer non-invasive screening test.

Importance: Colorectal cancer represents approximately 8% of all new cancer cases and is the third most commonly diagnosed cancer in the United States.¹ Screening and early detection have a significant role in reducing the impact of this preventable and treatable disease.

Continuous Glucose Monitoring (CGM) Utilization for Patients With Diabetes: Assesses the percentage of persons 18-75 years of age with diabetes who had evidence of CGM utilization during the measurement period.

Importance: Continuous glucose monitoring supports diabetes management and helps prevent hypoglycemic and hyperglycemic events and other life-threatening complications.² Continuous Glucose Monitoring Utilization for Patients With Diabetes is a utilization measure that provides visibility into CGM use patterns.

Intimate Partner Violence (IPV) Screening and Follow-Up: Assesses the percentage of persons 12-64 years of age who were screened for intimate partner violence using a standardized instrument, and who received follow-up care within 7 days of a positive intimate partner violence screening.

Importance: Intimate partner violence is a prevalent public health issue that harms individuals across every demographic group, with approximately 1 in 4 women and 1 in 7 men experiencing IPV in their lifetime in the U.S.³ Screening and follow-up for IPV provide a standardized manner for healthcare teams to collect information about potential safety concerns and identify when additional assessment, support or referrals may be needed.

Person-Centered Outcome Measures (3 Measures):

• Person-Centered Outcome–Goal Identification: Assesses the percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal.
• Person-Centered Outcome–Goal Follow-Up: Assesses the percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and followed up on the goal.
• Person-Centered Outcome–Goal Achievement: The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and achieved the goal.

Importance: There is broad agreement that an individual’s goals and priorities should guide care and the quality measures used to evaluate care.^4-6 For older adults with multiple chronic conditions and functional limitations, clinical guidelines have indicated the importance of providing goal-based care.^7,8 For this complex population, goal setting has been shown to reduce patient-reported treatment burden and unwanted care, and it correlates with greater physical and social well-being and higher care satisfaction.^9,10

Prenatal Syphilis Screening and Follow-Up: Assesses the percentage of deliveries that had a syphilis screening with a documented result during the first trimester, within 14 days of the first pregnancy diagnosis or prenatal visit, or within 30 days of enrollment in the organization, and the percentage of deliveries with a positive syphilis screen that received appropriate follow-up care.

Importance: The prevalence of congenital syphilis is increasing exponentially in the U.S., with a maternal-infant transmission rate of almost 90%. In 2024, 3,941 infants were born with congenital syphilis–a nearly 700% increase from 2015, when only 495 cases were reported.¹¹ Syphilis screening and timely follow-up during pregnancy have a significant role in reducing the impact of transmission and adverse health outcomes for both the pregnant person and baby.

Proposed Changes to Existing HEDIS Measures

Adult Immunization Status: Assesses the percentage of adults 19 and older who are up-to-date on recommended routine vaccines. The measure includes separate rates for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap); zoster; pneumococcal; hepatitis B; and coronavirus disease (COVID-19).

NCQA proposes two updates to the pneumococcal indicator:

• Expanding the denominator age range from 65 and older to 50 and older.
• Adding an age stratification for 50-64 in addition to the existing 65 and older stratification.

Emergency Department Utilization: Assesses the risk-adjusted ratio of observed to expected emergency department visits during the measurement period. NCQA proposes to expand this measure into the Medicaid product line for persons 18-64 years of age.

Pharmacotherapy Management of COPD Exacerbation: Assesses whether appropriate medications were dispensed following a chronic obstructive pulmonary disease (COPD) exacerbation for people 40 years of age and older within Medicare, Medicaid and Commercial product lines. The measure includes two separate rates: one that assesses whether a systemic corticosteroid is dispensed within 14 days of a COPD exacerbation event, and one that assesses whether a bronchodilator is dispensed within 30 days of a COPD exacerbation event.

NCQA proposes the following modifications to the measure:

• Adding an exclusion for individuals with asthma.
• Updating the denominator to count people instead of events and including additional qualifying COPD exacerbation events.
• Updating the numerator to include only one rate and revising medication lists.

How to Participate in Public Comment

The public comment period ends at 5:00 p.m. (ET) on Friday, March 13. Visit My NCQA to submit comments. We’ve made some improvements to our site to make it easier for you to submit your comments.

For details on proposed changes, visit the NCQA website.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

References

­¹American Cancer Society. (2023). Colorectal Cancer Facts & Figures 2023-2025. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2023.pdf.

²American Diabetes Association. (2026). Continuous Glucose Monitors. https://diabetes.org/advocacy/cgm-continuous-glucose-monitors.

³Stylianou, M.A. (2018). Economic Abuse Within Intimate Partner Violence: A Review of the Literature. Violence and Victims, 33(1), 3. https://connect.springerpub.com/content/sgrvv/33/1/3.full.pdf.

⁴McGlynn, E. A., Schneider, E. C., & Kerr, E. A. (2014). Reimagining Quality Measurement. New England Journal of Medicine, 371(23), 2150–2153. https://doi.org/10.1056/NEJMp1407883.

⁵Reuben, D. B., & Tinetti, M. E. (2012). Goal-oriented patient care—An alternative health outcomes paradigm. The New England Journal of Medicine, 366(9), 777–779. https://doi.org/10.1056/NEJMp1113631.

⁶Tinetti, M. E., Naik, A. D., & Dodson, J. A. (2016). Moving From Disease-Centered to Patient Goals–Directed Care for Patients With Multiple Chronic Conditions: Patient Value-Based Care. JAMA Cardiology, 1(1), 9. https://doi.org/10.1001/jamacardio.2015.0248.

⁷American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. (2012). Patient-centered care for older adults with multiple chronic conditions: A stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Journal of the American Geriatrics Society, 60(10), 1957–1968. https://doi.org/10.1111/j.1532-5415.2012.04187.x.

⁸The American Geriatrics Society Expert Panel on Person-Centered Care. (2016). Person-centered care: A definition and essential elements. Journal of the American Geriatrics Society, 64(1), 15–18. https://doi.org/10.1111/jgs.13866.

⁹Tinetti, M. E., Naik, A. D., Dindo, L., Costello, D. M., Esterson, J., Geda, M., Rosen, J., Hernandez-Bigos, K., Smith, C. D., Ouellet, G. M., Kang, G., Lee, Y., & Blaum, C. (2019). Association of Patient Priorities–Aligned Decision-Making With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple Chronic Conditions: A Nonrandomized Clinical Trial. JAMA Internal Medicine, 179(12), 1688–1697. https://doi.org/10.1001/jamainternmed.2019.4235.

¹⁰Kuipers, S. J., Cramm, J. M., & Nieboer, A. P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Services Research, 19(1), 13. https://doi.org/10.1186/s12913-018-3818-y.

¹¹Centers for Disease Control and Prevention. (2025). Sexually transmitted infections surveillance, 2024 (provisional).

The post HEDIS® Public Comment Period Is Now Open appeared first on NCQA.

Public comment is your opportunity to weigh in on the relevance, scientific soundness and feasibility of new and revised measures for HEDIS. Your feedback helps us determine changes to our programs, procedures and processes.

This year’s public comment is open February 13–March 13.

What Are We Seeking Feedback On?

We’d like input on:

• Seven new HEDIS measures.
• Revising three HEDIS measures.

Why Should You Comment?

NCQA measures are based on published clinical guidelines and scientific evidence. When guidelines change or new evidence becomes available in scientific literature, NCQA reviews measures to determine if measure changes may be needed.

NCQA convenes multi-stakeholder advisory panels—including independent scientists, clinicians, health plans, purchasers, government and consumer groups—to ensure that measures meet and balance the high standards of relevance, scientific soundness and feasibility.

Public review and comment is an important part of developing and updating HEDIS measures. NCQA reviews all comments received during public comment and presents results to advisory panels and to the NCQA Committee on Performance Measurement for deliberation.

How Can You Comment?

This year’s public comment will go live Friday, February 13, at 9:00a.m. ET.

We’ll post the link and more details here, so check back on February 13.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post Heads Up: HEDIS® Public Comment Opens Next Week appeared first on NCQA.

Re-Thinking Our Approach to Population Health

NCQA’s Wellness and Health Promotion Accreditation and Certification program has been in place for more than a decade, helping organizations design programs that engage people in improving their health. In 2025, NCQA started the Innovations in Wellness and Condition Management Working Group to update the program to reflect best practices and new technologies for evaluating population risk and providing self-management and coaching to help improve health outcomes. This is part of a larger effort to evaluate how high-quality, effective population health services are delivered across NCQA programs.

“As an industry, we have an opportunity to redefine our approach to population health and how we prevent and manage chronic disease,” says Rachel Harrington, PhD, NCQA’s Senior Product Strategist. “We know that 40-60% of the factors that influence a person’s health come from outside the walls of the healthcare system. With limited resources, especially in primary care and behavioral health, it is important to help support people in managing their health, including the use of digital technologies.”

In 2026, NCQA will start shaping these new standards, focusing on evaluating outcomes and supporting confident decision-making on digital health and wellness solutions. This isn’t just a focus for NCQA. “It’s validating to see that our work aligns with the CMS Innovation Center’s new ACCESS model,” says Harrington. “We hope it will motivate organizations to innovate and improve the patient experience.”

Understanding Health Differences Within Populations and Communities

Improving population and community health requires organizations to identify variations in health outcomes, look for the root causes and target solutions to populations and communities. The upstream, structural and personal factors that drive differences in health outcomes are complex and multifaceted—and often require data, investments and partnerships broader than the healthcare system. NCQA’s Accreditations in Health Outcomes and Community-Focused Care give organizations a framework to understand differences and close gaps.

“We’ve updated our program to give organizations more ways to view population and community health and a greater ability to tailor the program to the areas most relevant to the populations they serve,” says Elizabeth Ryder, NCQA’s Assistant Director, Product Management. “For example, disability status is a new population focus for Health Outcomes Accreditation, which complements a new HEDIS^® measure that we introduced in measurement year 2026.”

Listen to our podcast, One in Four: Making Disability a Quality Priority, to learn more about these changes.

Shaping the Future of Primary Care

Primary care is evolving at an astounding pace. NCQA’s Patient-Centered Medical Home Recognition program laid the foundation by providing an operational and quality improvement framework for primary care. Now, we are helping practices advance their relationships with payers and succeed in value-based care.

“We are looking at the next horizon for primary care,” says Jeff Sitko, NCQA’s Assistant Vice President, Product Management. “We have an opportunity to create a best practice, scalable delivery model that provides a blueprint for primary care practices to continue developing their capabilities. We want to work side-by-side with practices to understand what’s valuable and realistic, while also reducing administrative burden.”

Stay tuned for an announcement about our primary care partners. In the meantime, listen to our Quality Matters podcast, What’s New and What’s Next for Primary Care.

Integrating Primary Care and Behavioral Healthcare

People with mental health conditions and substance use disorders are more likely to experience chronic health conditions like heart disease and diabetes. Similarly, people who are living with chronic conditions may struggle with depression or anxiety. Integrated care models that combine behavioral health and primary care can improve access and coordination, leading to better health outcomes.

“We need more care delivery models that support whole-person care,” says Julie Seibert, PhD, NCQA’s Assistant Vice President, Behavioral Health. “Integrating behavioral health and primary care can improve access and coordination of care by meeting people where they are and implementing a ‘no wrong door’ policy when it comes to accessing behavioral health services.”

In 2026, NCQA will continue to promote integration, with funding from the Health Resources and Services Administration, to support Federally Qualified Health Centers and Look-Alike Health Centers seeking NCQA’s Distinction in Behavioral Health Integration.

We’ve also updated our Behavioral Health Accreditation program to strengthen the focus on population health and network adequacy. Read our blog post, Behavioral Health Accreditation Promotes Accountability, to learn more.

Advancing the Transition to Digital Quality Measurement

The transition to digital quality measurement is accelerating as healthcare moves rapidly toward interoperability and real-time data exchange. Most HEDIS measures are available in a digital format, ready for implementation. From building CQL engines to integrating digital measures at the point of care, organizations are making progress and showing tangible results.

“The year 2030 is our north star to become fully digital, and industry alignment is critical for success,” says Tricia Elliott, NCQA’s Vice President, Quality Implementation. “There are three parallel tracks that need to converge for us to continue forward progress: updates to the CMS Digital Quality Measures Roadmap, conversion of data to the HL7^® FHIR^® standard and clarity on the use of USCDI Core versus USCDI QI Core standards. The more we can build alignment, the easier it will be for everyone to do the work we need to do by 2030.”

In 2026, we anticipate broader adoption of digital HEDIS measures, supported by certification and parallel testing. NCQA recently launched a Digital Quality Measure Evaluation Package that includes a sample of digital HEDIS measures and supporting tools to help explore, test and plan your transition with confidence. Our Digital HEDIS Directory highlights how organizations are using NCQA’s digital HEDIS measures to modernize care delivery, drive efficiencies and improve outcomes.

Visit NCQA’s Digital Quality Hub for more resources to support your transition.

Expanding Use of Clinical Data in HEDIS^®

HEDIS is evolving to provide a more complete picture of care for populations, enabled by increased integration of clinical data. In Measure Year  2026, we will implement six new Electronic Clinical Data Systems (ECDS) measures and three measures will transition to ECDS-only.

“While every organization is on its own journey in incorporating clinical data, what remains constant is the trust in a reported HEDIS rate,” says Taylor Musser, NCQA’s Director, Measure and Data Operations. “This is driven in part by the audit requirements holding all organizations to the same expectations for data contributing to HEDIS. While a measure may be new or updated, the HEDIS Compliance Audit^™ helps to ensure an apples-to-apples comparison as HEDIS evolves.”

Read our blog post, HEDIS MY 2026: What’s New, What’s Changed, What’s Retired, to learn more about what you can expect in 2026.

Improving Quality of Care for Patients with Cardiovascular-Kidney-Metabolic Syndrome

NCQA conducted three expert convenings in 2025 to gather insights and help define our quality measurement approach related to Chronic Kidney Disease and Cardiovascular-Kidney-Metabolic (CKM) Syndrome. We are excited to accelerate this work in 2026.

“We’re interested in exploring quality measures that focus on risk assessment and prevention because if you can prevent one of these CKM-related diseases, you can often prevent them all,” says Caroline Blaum, MD, NCQA’s Assistant Vice President, Chronic Conditions and Complex Care. “I anticipate that 2026 will be a year of significant progress as we define our measurement approach and begin testing with real-world data.”

NCQA recently released a white paper that synthesizes what we learned from the convenings and makes recommendations for a holistic approach to the prevention and management of CKM syndrome.

Defining High Quality Diabetes Care

Diabetes is one of the diseases intertwined within the CKM framework. NCQA’s Diabetes Recognition Program recognizes clinicians who use evidence-based measures to provide high-quality care to patients with diabetes. We added three new measures to the program for 2026: Statin Therapy Prescription, Depression Screening and Follow-Up and Continuous Glucose Monitoring (CGM) Utilization. The CGM Utilization measure is the first step toward understanding and quantifying the growing use of this technology.

“The new CGM Utilization measure will help us understand where the technology is being used, which populations are using it and whether there are barriers limiting adoption,” says Emily Hubbard, MPH, NCQA’s Senior Research Associate. “Our goal is to standardize the data to help organizations capture and report on utilization within a defined population of patients with diabetes. This effort will lay the groundwork for NCQA to develop a broader CGM performance measurement approach in the future.”

Learn more about recent updates to the Diabetes Recognition Program, or access the standards in the NCQA store.

Reducing the Administrative Burden of Utilization Management

NCQA continually evaluates its standards and programs to ensure they remain relevant and useful for the industry. This includes reducing administrative burden so organizations can focus on what matters most: providing high-quality, accessible care. Interoperability is the key to transforming cumbersome processes, like prior authorizations.

“In 2026, we will start to see the impact of the CMS Interoperability and Prior Authorization Final Rule, which should make the process less burdensome and more efficient,” says Tsveta Polhemus, NCQA’s Assistant Vice President, Product Management. “NCQA’s revised utilization management standards are tightly aligned with the federal rules, and extend beyond them, as we also include commercial plans. We provide guidance to help plans analyze denial and appeal rates to identify what’s working and what’s not so they can provide a better experience for clinicians and patients.”

Read our blog post, Breaking Down Silos in Utilization Management: A Data-Driven Approach, to learn more about the updates to NCQA’s utilization management standards.

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An updated version of the measure was released for MY 2026, allowing additional data sources for reporting measure components. Given the changes outlined in the CY 2026 Physician Fee Schedule, the recent code updates made to the SNS-E measure will be retracted in the HEDIS MY 2026 Technical Update.

What Is the SNS-E Measure?

The SNS-E measure is specified for the Electronic Clinical Data Systems (ECDS) reporting method, which leverages data from EHRs, registries, HIEs, case management systems and claims. This measure assesses the percentage of people screened for unmet food, housing and transportation needs, and the percentage of people with a positive screen who received a corresponding intervention within 30 days. The measure includes six rates, a screening and intervention rate for each of the three social domains. It is reported for all ages and all product lines—Medicaid, Medicare and Commercial.

Recent Measure Updates in MY 2026

Following the release of the 2024 Physician Fee Schedule, which included the addition of the HCPCS G0136 code (defined as “Administration of a standardized, evidence-based SDOH assessment, 5–15 minutes”) NCQA added the following administrative codes to the measure in MY 2026 to support standardized reporting:

• HCPCS G0136 for provider-administered SDOH assessments.
• ICD-10 Z codes for identifying social needs for intervention.

What’s Changing in the MY 2026 Technical Update?

The 2026 Physician Fee Schedule modifies the description for the G0136 code to: “Administration of a standardized, evidence-based assessment of physical activity and nutrition.” It no longer includes assessments for upstream drivers of health. Because this code no longer aligns with SNS-E’s intent, NCQA is making the following updates in the MY 2026 Technical Update:

• Removing HCPCS G0136 from screening numerators.
• Removing ICD-10 Z59 codes (related to housing, food, transportation) from intervention denominators, as they can no longer be linked to standardized screenings via G0136.
• Additional minor updates to value sets and specifications.

What’s NOT Changing in the MY 2026 Technical Update?

• Use of LOINC codes corresponding to standardized screening questions to report the SNS-E measure.
• Removal of assessments from allowable interventions.

Impact of the Changes

The addition of the G0136 code was intended to reduce documentation burden by providing an additional administrative code to capture social needs screening, rather than relying solely on the submission of LOINC codes. Because recent changes to the code’s definition no longer align with that intent, the SNS-E measure will revert to its original specification.

Looking Ahead

NCQA remains committed to advancing measurement that captures social needs to improve care quality and outcomes. As the evidence base for social drivers of health and the policy landscape evolve, we will continue to adapt the SNS-E measure while maintaining its underlying intent: to help health plans identify and address unmet social needs that impact health.

Stay tuned for the MY 2026 Technical Update in March 2026, which will include the updated Social Need Screening and Intervention (SNS-E) measure specification.

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HEDIS Began in Partnership With Large Employers

HEDIS originated from conversations between large employers and health plans about the need to improve health care quality. It wasn’t long before they reached consensus: The nation needed a standard way to measure quality that would enable health care purchasers to compare health plans. Their solution was the Health Plan Employer Data and Information Set, later renamed “Healthcare Effectiveness Data and Information Set.”

NCQA was a new organization when it became responsible for developing and maintaining HEDIS. The first HEDIS measure set was released in 1993, and quickly became the national standard for health plan performance reporting.

HEDIS Defines Quality and Value in Health Care

HEDIS helps purchasers make “apples-to-apples” comparison of health care organizations by answering questions such as:

• How effectively are care and services delivered?
• How easy is it to access care?
• Are evidence-based health care services provided to the right person at the right time?
• Do services lead to better health outcomes?

An important—and unique—component of HEDIS is its attention to statistical details. HEDIS measures use a set of rules that can be unambiguously interpreted and consistently applied across organizations. Every organization that reports HEDIS must undergo a HEDIS Compliance Audit™—an independent, objective review of its information systems capabilities and HEDIS reporting processes to certify the accuracy of results.

Because they are a trusted source of quality data, HEDIS measures are included in value-based arrangements between health plans and providers, as well as in government quality performance programs such as the Centers for Medicare & Medicaid Services Medicare Advantage Star Ratings Program and Medicaid Core Sets. NCQA also uses HEDIS data as part of its Health Plan Ratings and makes that data available to help benchmark plan performance through its Quality Compass^® tool.

The Future of HEDIS Is Digital

HEDIS measures are evolving to be “digital first.” HEDIS digital quality measures are an important part of NCQA’s strategy to improve quality measurement and encourage the exchange of health information. In 2021, NCQA began offering HEDIS digital measures that use the Fast Healthcare Interoperability Resources (FHIR^®) standard, which enables better exchange of electronic health information, and aligns with new regulations that support interoperability. NCQA’s roadmap plans to make HEDIS fully digital by 2030.

Register for HEDIS 101 Today!

Whether you’re new to HEDIS or want to refresh your knowledge, you’ll gain new insights from our recently updated, self-guided HEDIS 101 course.

• Trace the path of HEDIS from its origins to its current role as the national standard for health care quality.
• Find out how HEDIS is evolving to meet new challenges, and why it matters for improving care.
• Learn how HEDIS measures are built, tested and updated to stay accurate and relevant.
• Understand the importance of reliable and valid measure results, and learn about the validation and certification programs that build trust in HEDIS.
• Find out how population differences and data quality can affect HEDIS results.
• Discover how health plans, providers, policymakers and communities use HEDIS to support better care and outcomes.

It only takes about an hour to complete our self-guided HEDIS 101 course. Register today and share it with your team to get up to speed on the present—and future—of HEDIS.

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HEDIS Compliance Audit™ is a trademark of the National Committee for Quality Assurance (NCQA).

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Here’s a sample of our most popular self-paced courses. Complete them online any time, at your convenience.

HEDIS 101: Introduction to the Healthcare Effectiveness Data and Information Set

HEDIS is the most widely used system for measuring health care quality in the U.S. In this online, self-paced course, you’ll learn what HEDIS is, why it matters and how you can leverage its insights to drive better outcomes. This course is for quality improvement professionals who are new to HEDIS or want to deepen their understanding.

Introduction to the Digital Quality Transition

This online, self-paced course will provide a foundation in digital quality measurement: why it’s important, and how your organization can make a successful transition. This course is designed for quality and data reporting professionals working in health plans, health systems and technology organizations.

Health Plan Accreditation Survey Year 2026 Updates

This course includes seven self-paced modules covering updates, changes and policy clarifications for the Health Plan Accreditation standards and guidelines. It’s a great resource to help health plans, consultants, policymakers and vendors stay up to date on the latest requirements.

Accreditation in Utilization Management

This course provides a comprehensive explanation of updates and changes to NCQA’s Utilization Management Accreditation, including quality improvement for utilization management, collaboration with delegates, timeliness of decisions and more. NCQA surveyors and staff guide learners through requirement updates and their implications.

NCQA Essentials for Case Management

This course is designed for clinicians and health care professionals who are responsible for case management operations. It covers the fundamentals of case management—from systematic evidence reviews through care transitions—and takes a deep dive into the practical applications of case management, including working with interdisciplinary teams and helping to ensure that patients receive timely and appropriate care.

Introduction to PCMH 2026

This introductory course focuses on the fundamentals of the PCMH Recognition program, including the core elements and how to gather evidence to show compliance. Participants will also learn about policies, processes and procedures that help a practice transform into a medical home.

Advanced PCMH 2026

This advanced course takes a deeper dive into each PCMH concept and explores the characteristics of a successful medical home and the assessment process. It also focuses on advanced topics such as behavioral health integration, electronic clinical quality measures and how to receive automatic credit for certain standards. To get the most from this course, participants should have a working knowledge of the PCMH Recognition program.

Note: Save $395 when you bundle the Introduction to PCMH and Advanced PCMH courses.

Virtual Care Accreditation Essentials for PCMH Practices

This course will help participants from PCMH Recognized practices understand the value of NCQA’s Virtual Primary Care Accreditation, the similarities and differences between PCMH and Virtual Care standards and how to get started. Participants will also hear from a practice that achieved Virtual Care Accreditation.

PCMH Recognition Annual Reporting 2026: Continued Success

Learn about the goals of Annual Reporting and how to prepare for annual submission under PCMH Recognition. This course is designed for individuals working in PCMH practices who have at least one year of experience collecting, reporting and acting on annual reporting data.

Learn More

View our library of NCQA education courses here. To schedule training for a team, please contact us.

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Know Your MY 2025 Reporting Requirements

Health plans report HEDIS for many reasons, including for participation in public and private quality programs. Most programs have released their MY 2025 measure sets. For example, CMS released Medicare Advantage HEDIS requirements in June, and NCQA released the latest Health Plan Ratings methodology in October. Organizations should be familiar with the requirements.

Remember that measure specifications might have changed for MY 2025. Refer to HEDIS MY 2025: What’s New, What’s Changed, What’s Retired for a summary of changes. Updates may include changes to the data collection methodology (e.g., Childhood Immunization Status transitioned to ECDS reporting), or to the population assessed (e.g., Breast Cancer Screening lowered the screening start age from 52 to 42 years).

Understanding the technical specifications and referencing the predictive trending determinations can provide insight when evaluating preliminary MY 2025 rates.

Prepare for the HEDIS Compliance Audit™

All health plans reporting HEDIS MY 2025 must participate in a HEDIS Compliance Audit™. All licensed organizations and Certified HEDIS Compliance Auditors must follow a standardized methodology and provide an independent assessment of information systems, data management processes and final HEDIS rates. Auditors are not allowed to provide technical assistance or advisory services; their strict independence is what makes an audited HEDIS result trusted for public use.

The HEDIS Roadmap for the audit was released in September, and health plans should be working to meet the upcoming audit deadlines. Mark your calendar for these key 2026 dates.

Click here to view the complete HEDIS MY 2025 audit timeline.

Stay on Top of Data Submission Deadlines

A successful HEDIS submission starts with completing the Healthcare Organization Questionnaire. The online system opens in early December; health plans must submit their HOQ before the system closes on February 6, 2026.

The IDSS opens in March. Health plans should load data early to address system warnings and errors. All plan-locked data are due by Monday, June 1, 2026. An authorized representative must attest to the data as part of the final submission.

HEDIS MY 2025 reporting ends Monday, June 15, 2026, at 9:00pm (ET). Don’t wait until the last day to submit results! (Most organizations submit results early—only 2% were received on the final day for HEDIS MY 2024.)

View the full HEDIS MY 2025 Data Submission timeline here.

If you have any questions, or need support, please contact your NCQA Representative or submit a question at My NCQA. We wish you a successful HEDIS season!

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