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HEDIS®: General Guidelines and Measure Descriptions

HEDIS MY 2026 Highlights

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New Measures

The newest additions to HEDIS address acute hospitalizations following outpatient surgeries, health plan disability membership make-up, follow-up after acute and urgent care visits for asthma and tobacco use screening and cessation. HEDIS MY 2026: What's New, What's Changed, What's Retired - NCQA.

Four Risk Adjusted Utilization Measures

  • 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.

Intent: Most surgeries are performed in outpatient settings. Health plans can provide services that help ensure proper care coordination during the critical post-surgical period. NCQA sees this as a quality measurement gap to fill and developed these new measures to assess the quality of care provided by health plans after surgery.

One Health Plan Descriptive Measure

Disability Description of Membership (DDM). An unduplicated count and percentage of members enrolled at any time during the measurement year, by disability status and disability status source.

Intent: People with disabilities are more likely to report poorer overall health and have less access to adequate health care. In recognition of the need to advance equitable care and outcomes for people with disabilities, NCQA conducted an environmental scan and engaged with the disability and disability advocacy community to develop this measure. The measure intent is to encourage collection of disability information from members, which will enable future strategies for assessing quality of care for people with disabilities, such as measure stratification, risk adjustment and targeted measure development.

Two Reported ECDS Measures

Follow-Up After Acute and Urgent Care Visits for Asthma (AAF-E). The percentage of persons 5–64 years of age with an urgent care visit, acute inpatient discharge, observation stay discharge or ED visit, with a diagnosis of asthma, who had a corresponding outpatient follow-up visit, with a diagnosis of asthma, within 30 days.

Intent: Studies show that individuals with asthma frequently utilize acute and urgent care to address exacerbations, which are indicators of poorly controlled asthma. Clinical guidelines recommend follow-up with an outpatient care provider to assess asthma control and review medication use. This measure’s intent is to incentivize coordination of follow-up care in an appropriate time frame for patients experiencing asthma exacerbations.

Tobacco Use Screening and Cessation Intervention (TSC-E). The percentage of persons 12 years of age and older who were screened for commercial tobacco product use at least once during the measurement period, and received tobacco cessation intervention after being identified as a tobacco user.

Two rates are reported:

  1. Tobacco Use Screening. The percentage of persons who were screened for tobacco use.
  2. Cessation Intervention. The percentage of persons who were identified as a tobacco user and received tobacco cessation intervention (counseling or pharmacotherapy).

Intent: Commercial tobacco use is the leading cause of preventable disease, disability and death in the United States. Smoking cessation can reduce the risk of negative health effects, regardless of age or how long someone has been smoking. This measure expands NCQA’s focus on wellness and prevention, which aligns with national health care priorities. For more information, refer to the Tobacco Cessation blog post.

Retired Measures

  • Lead Screening in Children (LSC)*
  • Asthma Medication Ratio (AMR)
  • Statin Therapy for Patients With Cardiovascular Disease (SPC)*
  • Statin Therapy for Patients With Diabetes (SPD)*
  • Medical Assistance With Smoking and Tobacco Use Cessation (MSC)

*Only the LSC-E, SPC-E and SPD-E measures will be reported.

Overall Changes

  • Measure Specifications, Measure Medication List Directory and Measure Codes are subject to change by NCQA until the measures and codes are frozen by NCQA on March 31, 2026. NCQA will release an update noting any measure or code changes at that time.
  • Technical specification updates—HEDIS MY 2026 NCQA will freeze the specifications for MY 2026 on March 31, 2026, with the HEDIS MY 2026 Volume 2 Technical Update:
    • HEDIS MY 2026 Volume 2 Technical Update and Value Set Directory (3/31/2026 release) is available for download by customers with access to the HEDIS MY 2026 Volume 2 e-pub. 
    • The following guidelines and measures include corrections, policy changes and clarifications with the release of the MY 2026 Volume 2 Technical Update:
      • The NCQA HEDIS Compliance Audit™. 
      • General Guideline: HEDIS Reporting Date.
      • General Guideline: Race and Ethnicity Stratifications*. 
        Note: References to “Some Other Race” were changed to “Other Race” in this guideline. Affected measures that have race and ethnicity stratification (RES) criteria are identified with an asterisk (*). 
      • Controlling High Blood Pressure (CBP)*. 
      • Cardiac Rehabilitation (CRE).
      • Glycemic Status Assessment for Patients With Diabetes (GSD)*. 
      • Eye Exam for Patients With Diabetes (EED)*.
      • Kidney Health Evaluation for Patients With Diabetes (KED)*.
      • Osteoporosis Management in Women Who Had a Fracture (OMW). 
      • Osteoporosis Screening in Older Women (OSW).
      • Follow-Up After Hospitalization for Mental Illness (FUH)*.
      • Follow-Up After Emergency Department Visit for Mental Illness (FUM)*.
      • Follow-Up After High-Intensity Care for Substance Use Disorder (FUI).
      • Follow-Up After Emergency Department Visit for Substance Use (FUA)*.
      • Pharmacotherapy for Opioid Use Disorder (POD)*.
      • Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD).
      • Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA).
      • Advance Care Planning (ACP).
      • Transitions of Care (TRC).
      • Use of High-Risk Medications in Older Adults (DAE).
      • Use of Opioids at High Dosage (HDO).
      • Initiation and Engagement of Substance Use Disorder Treatment (IET)*.
      • Prenatal and Postpartum Care (PPC)*.
      • Well-Child Visits in the First 30 Months of Life (W30)*.
      • Child and Adolescent Well-Care Visits (WCV)*.
      • Plan All-Cause Readmissions (PCR).
      • Acute Hospitalizations Following Outpatient Colonoscopy (HFC).
      • Acute Hospitalizations Following Outpatient General Surgery (HFG).
      • Acute Hospitalizations Following Outpatient Orthopedic Surgery (HFO).
      • Acute Hospitalizations Following Outpatient Urologic Surgery (HFU).
      • Childhood Immunization Status (CIS-E)*.
      • Immunizations for Adolescents (IMA-E)*.
      • Breast Cancer Screening (BCS-E)*.
      • Cervical Cancer Screening (CCS-E)*.
      • Colorectal Cancer Screening (COL-E)*. 
      • Blood Pressure Control for Patients With Hypertension (BPC-E)*.
      • Statin Therapy for Patients With Cardiovascular Disease (SPC-E).
      • Statin Therapy for Patients With Diabetes (SPD-E).
      • Tobacco Use Screening and Cessation Intervention (TSC-E).
      • Adult Immunization Status (AIS-E)*.
      • Prenatal Immunization Status (PRS-E)*.
      • Prenatal Depression Screening and Follow-Up (PND-E)*.
      • Postpartum Depression Screening and Follow-Up (PDS-E)*.
      • Social Need Screening and Intervention (SNS-E).
      • Race/Ethnicity Description of Membership (RDM)*.
      • Appendix 2: Data Element Definitions.
      • Appendix 3: Contributors.
  • General Guidelines for Data Collection and Reporting Summary of Changes to HEDIS MY 2026:
    • Removed references to Medicare-Medicaid (MMP) plans because this is no longer a reporting option for MY 2026.
    • Deleted General Guideline: Date Specificity; requirements are included in each applicable measure.
    • Added General Guideline: Which Services Count to the Data Collection Methods and Data Sources section.
    • Updated General Guideline: Race and Ethnicity Stratifications to align with the March 2024 updates to the Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity.
    • Added text to Data refresh for the systematic sample in General Guideline: Obtaining Information for the Systematic Sample.
    • Deleted General Guideline: Measures That Use Medication Lists; requirements are included in each applicable measure.
    • Deleted General Guideline: Anchor Dates; requirements are included in General Guideline: Continuous Enrollment.
    • Updated General Guideline: Data Collection Methods to include information regarding the electronic method of reporting.
    • Deleted General Guideline: SNOMED Codes.
    • Updated terminology (replaced “measurement year” with “measurement period”; “members” with “persons”; “eligible population” with “initial population”; “required exclusions” with “denominator exclusions”).
    • Removed Source System of Record (SSoR) reporting from all ECDS reported measures. As NCQA expands the list of measures available for ECDS reporting, this update will simplify reporting and enable the transition to digital quality measurement. For additional information, refer to the ECDS webpage.
  • 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. Both 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 that targets people 65 and older.
  • Social Need Screening and Intervention (SNS-E). Updated the measure to add codes to identify screening numerator events and intervention denominator and numerator events and updated the I-SNP and LTI exclusions to include all ages.
    • After the initial MY2026 NCQA Specification changes were released in September 2025, NCQA announced in December 2025, 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 March 2026. In March 2026, the HEDIS MY 2026 Technical Update will provide the complete details. Refer to the SNS-E measure for additional information.
  • NCQA will allow voluntary ECDS reporting for the Blood Pressure Control for Patients With Diabetes (BPD-E) measure.

Retiring Codes

NCQA annually tracks codes that are designated obsolete. NCQA does not remove codes in the year in which they receive the designation of obsolete because of the look-back period in many HEDIS measures. Obsolete codes are deleted from the HEDIS specifications after the look-back period has passed.

 

Health Plan Descriptive Information Measures

Health Plan Descriptive Information Measures are one of the six domains of care within the Healthcare Effectiveness Data and Information Set (HEDIS®), developed and maintained by the National Committee for Quality Assurance (NCQA).

New Health Plan Descriptive Information Measure (MY 2026)

For Measurement Year (MY) 2026, the Health Plan Descriptive Information Measures in HEDIS include a newly introduced measure and updates to existing reporting elements.

Here's a breakdown:

 

DDM – Disability Description of Membership

  • Purpose: Captures the number of health plan members who identify as disabled any time during the measurement year.
  • Key Features:
    • Removed the previous age restriction (15+); now includes all ages.
    • Eliminated secondary disability type stratification.
    • Focuses on binary classification: disabled vs. not disabled.
    • If data sources conflict, the disabled status will be prioritized to avoid undercounting.
    • Members who respond “declined” or “prefer not to answer” are classified as missing disability status.
    • Collect data directly from members.

Race and Ethnicity (RES) Stratification is now required for the following measures:

  • Adult Immunization Status (AIS-E).
  • Blood Pressure Control for Patients With Hypertension (BPC-E).
  • Breast Cancer Screening (BCS-E).
  • Cervical Cancer Screening (CCS-E).
  • Child and Adolescent Well-Care Visits (WCV).
  • Childhood Immunization Status (CIS-E).
  • Colorectal Cancer Screening (COL-E).
  • Controlling High Blood Pressure (CBP).
  • Eye Exam for Patients With Diabetes (EED).
  • Follow-Up After Emergency Department Visit for Mental Illness (FUM).
  • Follow-Up After Emergency Department Visit for Substance Use (FUA).
  • Follow-Up After Hospitalization for Mental Illness (FUH).
  • Glycemic Status Assessment for Patients With Diabetes (GSD).
  • Immunizations for Adolescents (IMA-E).
  • Initiation and Engagement of Substance Use Disorder Treatment (IET).
  • Kidney Health Evaluation for Patients With Diabetes (KED).
  • Pharmacotherapy for Opioid Use Disorder (POD).
  • Postpartum Depression Screening and Follow-Up (PDS-E).
  • Prenatal and Postpartum Care (PPC).
  • Prenatal Depression Screening and Follow-Up (PND-E).
  • Prenatal Immunization Status (PRS-E).
  • Race/Ethnicity Description of Membership (RDM).
  • Well-Child Visits in the First 30 Months of Life (W30).

Report only one of the 10 categories for race and the total: 

Report only one of the 4 categories for ethnicity: 

Language Description of Membership  

 

Medicare Socioeconomic Status (SES) Stratification

Medicare members, are categorized by socioeconomic status (SES) stratification for the following measures:

  • Breast Cancer Screening.
  • Colorectal Cancer Screening.
  • Eye Exam for Patients With Diabetes.
  • Plan All-Cause Readmissions.

Medicare members will be reported in one of the six stratifications listed below including the total of all categories.

  • Non-LIS/DE, Non-disability: Member is eligible for Medicare due to age only (does not receive LIS, is not DE for Medicaid, does not have disability status).
  • LIS/DE: Member is eligible for Medicare due to age and receives LIS (includes members eligible for Medicare due to DE) and does not have disability status.
  • Disability: Member is eligible for Medicare due to disability status only.
  • LIS/DE and Disability: Member is eligible for Medicare due to age, receives LIS and has disability status.
  • Other: Member has ESRD-only status or is assigned “9—none of the above.”
  • Unknown: Member’s SES is unknown. May be >0 only for Puerto Rico plans, or if the auditor approved a small number of unassigned members*.
  • Total Medicare: Total of all categories above.

Best Practice and Measure Tips: How can I improve HEDIS scores?

  • Maximize use of codes: Only codes will close gaps for Administrative and Electronic Measures.
  • Submit claim/encounter data for every service in an accurate and timely manner.
  • Some measures collect more than one data element. Submit codes required for all elements.
  • Document medical and detailed surgical history with dates and use of appropriate coding. (Example: Documentation of Hysterectomy without reference to TOTAL, Radical, etc. will not exclude members from CCS Measure).
  • Information from the medical record must validate all required measures or exclusion components.
  • Each medical record/office note MUST contain:
    • Member Name
    • Date OF Birth (DOB)
    • Date OF Service (DOS)
      • Note regarding Faxes Requests: Information on a fax cover sheet cannot be used.Due to the limited data collection timeframe, a turnaround time of 3‐5 days is appreciated.
      • Under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule, data collection for HEDIS® is permitted, and the release of this information requires no special patient consent or authorization.
    • Follow the NCQA Guidelines for Medical Records Documentation.
  • Only completed events count toward HEDIS compliance.
  • Documentation in a medical record of a diagnosis or procedure code alone does not comply with the numerator criteria.
  • A date must be specific enough to determine whether a test or service was performed within the time frame specified, not merely ordered.
  • An undated event on a problem list or history sheet can be used as long as it is specific enough to determine that the event occurred during the timeframe specified in the measure.
  • Educate schedulers to review for needed screenings, tests and referrals.
  • Assist member with scheduling tests. Follow-up to ensure completes ordered screening.
  • Provide member education on disease process and rationale for tests.
  • Ask open-ended questions to determine any barriers to care or treatment.
  • Collaborating with other providers members receive services to help ensure care is comprehensive, safe and effective.
  • Ensure timely referrals to behavioral health professionals for members requiring follow-up care related to inpatient stays or medication management, in alignment with HEDIS behavioral health measures.
    • The Johns Hopkins Health Plans Care Management team offers a variety of services to help members who are living with mental health may receive confidential care management support and coordination of care from a Licensed Clinical Social Worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders. For Priority Partners members, we work with Carelon Behavioral Health of Mayland to manage mental health needs.
      • Please send us your referrals by contacting us at:
        Phone: 800-557-6916
        Monday through Friday: 8 a.m. to 5 p.m.
        Voicemail messages received after normal business hours will be addressed the following business day.
        EHP Behavioral Health: 410-424-4891
        EHP Behavioral Health (Secured): 410-424-4765
        USFHP Mental Health: 410-424-4839
        AMD Behavioral Health, Inpatient & Outpatient: 844-340-2217
        Email: [email protected]
  • Document any upcoming scheduled screening and name of provider who will be performing.
  • Incomplete information will not close gaps.
  • Not Acceptable: Documenting terms such as “recent,” “most recent”, “at a prior visit” or “Colonoscopy up to date”. These are not specific enough to know when an event occurred.

Required Enrollment

To ensure there is enough time for members to receive services, each measure has criteria for:

  • Continuous enrollment: Specifies the minimum amount of time that a member must be enrolled with an organization before becoming eligible for a measure.
  • A gap is the time when a member is not covered by the organization. An allowable gap can occur any time during continuous enrollment.

Measure Exclusions

Measure Codes

The National Committee for Quality Assurance (NCQA) uses a “Value Set Directory” to organize associated codes for each measure. NCQA uses Current Procedural Terminology (CPT) codes copyright 2026 American Medical Association.

Measure Codes listed for each measure are not all inclusive and subject to change based on the current NCQA Specifications for each measure. 

Measure Exclusion Code

HEDIS Terminology

Compliance

  • Elements which require the last result in the Measurement Year may impact member compliance throughout the year. (Example: A1c on March 6.0 = compliant. June A1c test no result reported. System will default to >9 until the result is received.)
  • Member ages for each measure are based on different criteria. This may impact the age range to include additional ages. (Example: 18 years of age by December 31 of the measurement year- Consider when member turns 18 and include service performed during the measurement year when member was 17.)

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