The National Committee for Quality Assurance (NCQA) has announced several upcoming changes to the Healthcare Effectiveness Data and Information Set (HEDIS®)1, which will impact how organizations measure and report quality of care.2 These updates are designed to enhance accuracy, reflect new clinical guidelines, and address emerging health priorities—but they also require compliance, data management, and performance improvement.
Getting ahead of HEDIS changes is not just about meeting requirements; it is an opportunity to strengthen your organization’s approach to quality, optimize workflows, and deliver better outcomes for members. In this blog, we will explore what’s changing, why it matters, and how proactive strategies, including advanced analytics, can help you navigate these changes.
What measures are new for 2026?
The latest HEDIS updates include new measures focused on acute hospitalizations following outpatient surgeries, health plan disability membership composition, follow-up care after acute and urgent asthma visits, and tobacco use screening and cessation:
Risk adjusted utilization measures
- Acute hospitalizations following outpatient surgeries: Four new measures have been introduced to assess the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations after specific outpatient procedures. These measures are designed to assess inpatient and observation stays for any diagnosis within 15 days of the outpatient surgical procedure and are applicable to patients 65 years of age and older. New measures include Acute Hospitalizations Following Outpatient Orthopedic Surgery (HFO), General Surgery (HFG), Colonoscopy (HFC), and Urologic Surgery (HFU).
Health plan descriptive measure
- Disability Description of Membership (DDM): This health plan descriptive measure tracks the unduplicated count and percentage of members enrolled by disability status, aiming to enhance data on care disparities among individuals with disabilities.
ECDS Reported Measures
Two measures will transition to Electronic Clinical Data Systems (ECDS) format to report follow-up care for:
- Follow-up After Acute and Urgent Care Visits for Asthma (AAF-E): This measure evaluates the percentage of acute asthma visits that are followed by an outpatient visit within 30 days, supporting improved asthma management and reducing exacerbations.
- Tobacco Use Screening and Intervention: Focused on members aged 12 and older, this measure tracks the percentage screened for tobacco use and the percentage of identified users who have receive cessation interventions. It replaces the previous Medical Assistance with Smoking and Tobacco Use Cessation (MSC) measure, which was captured through the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey responses.
EDCS reporting will also include:
NCQA will allow voluntary ECDS reporting for the Blood Pressure Control for Patients with Diabetes (BPD-E) measure and has retired the Administrative and Hybrid reporting methods for Lead Screening in Children (LSC), Statin Therapy for Patients with Cardiovascular Disease (SPC), and Statin Therapy for Patients with Diabetes (SPD), making ECDS the sole reporting method for these measures.
Which measures are scheduled for retirement?
NCQA is retiring the Asthma Medication Ratio (AMR) and Medical Assistance with Smoking and Tobacco Use Cessation (MSC) measures, which are defined below:
- Asthma Medication Ratio (AMR): The AMR measure differentiates between controller and reliever asthma medications. According to NCQA, this approach does not reflect current clinical guidelines recommending combined maintenance and reliever therapy. It also limits eligibility to individuals with persistent asthma—those with high health care utilization—resulting in a narrower population. Additionally, the complex numerator calculation and inconsistent medication data create challenges for accurate performance measurement.
- Medical Assistance with Smoking and Tobacco Use Cessation (MSC): This survey-based measure focuses only on current adult tobacco users and excludes screening rates and adolescents. It is being replaced by the Tobacco Use Screening and Cessation Intervention measure, which expands the scope to individuals aged 12 and older and evaluates both screening for commercial tobacco use and evidence-based cessation interventions.
What changes have been made to existing measures?
Existing measure formats have been updated to align with CMS and NCQA’s Digital Roadmap and alignment with FHIR® data standards and are similar to HEDIS ECDS reported measures.3
Terminology changes include replacing eligible population with initial population, required exclusions with denominator exclusions, measurement year with measurement period and member with person.
Additional changes to existing measures include:
- Follow-Up After High-Intensity Care for Substance Use Disorder (FUI): Updated the measure to allow substance use disorder diagnoses in any position on the follow-up claim. The measure expanded the numerator to include peer support services as an appropriate follow-up visit.
- Statin Therapy for Patients with Cardiovascular Disease (SPC-E) and Statin Therapy for Patients with Diabetes (SPD-E): Updated the cardiovascular measure to remove sex-specific age bands.th measures removed the “I-SNP or long-term institutional (LTI) care” exclusion, and the approach for identifying atherosclerotic cardiovascular disease (ASCVD) was updated.
- Adult Immunization Status (AIS-E): Added a COVID-19 indicator to the measure targeting individuals 65 and older.4
- Social Need Screening and Intervention (SNS-E): Updated the measure to add codes to identify screening numerator events and intervention denominator as well as numerator events, and updated I-SNP and LTI exclusions to include all ages.
What is the impact on quality assessment?
These updates are designed to improve the quality of care delivered particularly in addressing emerging health needs and enhancing care coordination after outpatient surgeries. Overall, these changes reflect NCQA’s commitment to evolving HEDIS measures in line with clinical best practices, supporting healthcare organizations in their mission to deliver high-quality, equitable care.
In addition, NCQA is leading a major transformation in healthcare quality measurement by transitioning from traditional HEDIS hybrid measures to digital formats (such as ECDS and FHIR) to enhance data efficiency and interoperability. This shift requires health plans and ACOs to upgrade technical systems and build capabilities to support fully digital quality reporting, especially for risk-adjusted and stratified measures. By investing and planning proactively now, health plans and ACOs can secure a strong position in the fully digital reporting environment NCQA is designing for the future of healthcare quality measurement.
Why is accurate data important for HEDIS?
Accurate data and effective risk adjustment are essential to achieving strong HEDIS and quality performance because they ensure results truly reflect the complexity of the populations being measured.
HEDIS scores drive quality ratings, reimbursement, and public reporting, but without accurate and complete data, performance can be misrepresented. Gaps in clinical, claims, and supplemental data can lead to missed numerator credit, incorrect exclusions, and underreported outcomes, all of which negatively impact quality scores and star ratings.
Risk adjustment adds critical context by accounting for differences in patient acuity, comorbidities, and social risk factors. When risk is not fully captured, organizations caring for more complex or vulnerable populations may appear to perform worse than they are . Accurate risk adjustment ensures fair comparisons, more precise benchmarking, and appropriate reimbursement tied to true patient complexity.
How can Milliman MedInsight help your organization prepare for HEDIS?
As part of a Risk Adjustment Suite, the Milliman MedInsight Risk Adjustment Platform helps organizations address these challenges by integrating and validating data from multiple sources, identifying documentation gaps, and ensuring diagnoses are accurately captured and supported. By improving data integrity and risk capture, Milliman MedInsight enables health plans and provider organizations to optimize HEDIS performance, strengthen quality outcomes, and confidently demonstrate the value of the care they deliver across all lines of business. With flexible implementation options, from turnkey deployment to customized configurations, the platform can be tailored to meet each organization’s unique needs.
The Risk Adjustment Platform’s core offering includes:
- Data acquisition: Collects claims, clinical, and CMS data into a unified environment.
- Data enrichment: Layers in HCC coding insights and risk-related attributes for more precise stratification.
- Recapture analytics: Applies sophisticated algorithms and AI to analyze data, generate tailored reports, and streamline coding workflows efficiently.
Additional products and services include:
- Clinical coding and CMS compliance: Drives accurate reimbursement while supporting informed clinical decision-making, improved patient outcomes, and high-quality data for quality measurement and research.
- Self-service RADV software: Empowers organizations with flexible, self-service RADV tools, supported by software licensing and training to manage audits with confidence.
- Clinical data and EHR interoperability: Enables seamless data exchange through direct API connections to leading EHRs (Epic, Cerner, eCW), HIEs, national aggregators, and bidirectional reporting, creating a more complete and trusted data foundation.
- Coding staff augmentation: Provides access to experienced coding professionals who perform thorough chart audits, proactively identify and resolve coding gaps, and support comprehensive pre- and post-visit reviews.
- Actionable benchmarks: Leverages Milliman benchmarks (such as MANI, ACO Builder, and STARS cut points) to deliver clear insights into market performance across risk, cost, and quality measures.
The Risk Adjustment Platform also includes a robust library of quality measures through MedInsight Evidence-Based Measures (EBMs). At the core of the EBM framework is the ability to accurately identify relevant populations for each measure and assess which members are compliant with established quality guidelines. Measure concepts and specifications are informed by leading industry organizations, including the National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institute of Medicine (IOM), NCQA, and the American Medical Association (AMA). MedInsight EBMs have also earned NCQA certification for HEDIS® Measure Year (MY) 2025.
Furthermore, Milliman MedInsight continuously monitors updates to measure definitions and regulatory requirements. By proactively tracking and interpreting these changes, we help reduce administrative burden so clients can stay focused on their core operations. With dedicated support and ongoing guidance, Milliman MedInsight enables organizations to maintain compliance with confidence, minimize risk, and consistently meet their performance and reporting goals.
What resources are available?
Schedule a call: Connect with one of our healthcare analytics experts.
Visit our website: Learn more about our Risk Adjustment Suite and Risk Adjustment Platform, a comprehensive, end-to-end risk adjustment solution.
Watch the webinar: Register to attend our webinar “Integrated risk adjustment solutions: Enhancing reimbursement and patient care” and learn how to optimize risk adjustment, RADV audits, and HEDIS gap closures.
References:
1. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
2. HEDIS MY 2026: What’s New, What’s Changed, What’s Retired – NCQA
3. FHIR® is a registered trademark of Health Level Seven International.
4. Milliman continues to monitor ongoing changes in vaccine recommendations and quality measure specifications to ensure our insights remain relevant and responsive to industry developments.
