HEDIS Quality Measures: Complete Guide for Health Plans & Providers (2026)

Master HEDIS quality measurement, understand the eight domains, learn measure definitions, and discover proven strategies to improve performance and STAR ratings.

What is HEDIS?

HEDIS measures reflect best practices in healthcare delivery. They assess preventive care utilization, chronic disease management, mental health treatment, medication management, and patient experience. NCQA updates HEDIS specifications annually to reflect evolving clinical evidence and healthcare priorities.

Why HEDIS Measures Matter

STAR Ratings and Bonus Payments

HEDIS performance directly determines Medicare Advantage STAR ratings, which range from 1 to 5 stars. CMS pays bonus payments based on STAR ratings: a 5-star plan receives 5-8% bonus payment above benchmark; 4-star plans receive 3-5% bonus; 3-star plans receive 0-3% bonus; 2-star plans receive no bonus; 1-star plans may be penalized.

For a $200M health plan, each STAR point difference represents $10-20M in annual bonus revenue. HEDIS improvement directly translates to financial performance.

Public Reporting

HEDIS measures are publicly reported on Medicare.gov, enabling members and employers to compare plan performance. Plans with poor HEDIS scores experience enrollment loss and reduced member satisfaction.

Regulatory Compliance

Plans must submit HEDIS data to NCQA according to strict specifications. Submission errors can result in audit penalties, corrected submissions, and reputational damage.

The 8 HEDIS Domains

1. Effectiveness of Care

Measures adherence to clinical guidelines for common conditions and preventive services. Examples:

• Colorectal Cancer Screening (COLO)
• Breast Cancer Screening (BCS)
• Diabetes Screening (RPD, HbA1c Testing)
• Blood Pressure Control in Hypertension (BPC)

2. Access and Timeliness

Measures member access to care and appointment scheduling. Examples:

• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)
• Preventive Care and Screening (PCS)

3. Member Experience

Captures member satisfaction through surveys. Example:

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey

4. Behavioral Health

Measures mental health and substance use treatment. Examples:

• Mental Health Treatment Engagement
• Antidepressant Medication Management (AMM)
• Medication for Opioid Use Disorder (OUD)

5. Medication Management

Measures appropriate medication use and adherence. Examples:

• Medication Adherence for Chronic Conditions (Asthma, Diabetes, Hypertension)
• Statin Use in High-Risk Populations

6. Care Coordination

Measures coordination between providers and care settings. Examples:

• Plan All-Cause Readmission (PCR)
• Imaging Overuse (OIU, OPI)

7. Utilization Management

Measures appropriate use of healthcare services and cost management. Examples:

• Hospital Readmission Rates
• Emergency Department Utilization

8. Risk-Adjusted Utilization

Measures utilization after adjusting for member risk. Examples:

• Total Cost of Care
• Risk-Adjusted Inpatient Utilization Rate

Most Impactful HEDIS Measures by Domain

Hybrid vs. Administrative vs. Electronic Measures

Administrative Measures

Source: Claims and encounter data only. No medical record review required.

Examples: Breast cancer screening, mammography coding claims only.

Pros: Quick to report, lower operational cost.

Cons: Limited accuracy (no clinical validation); misses services not billed.

Hybrid Measures

Source: Claims supplemented by medical record review (abstraction).

Examples: Colorectal cancer screening (claims + chart for colonoscopy documentation); diabetes monitoring (claims + labs from charts).

Pros: Higher accuracy; captures all services including uncompensated care.

Cons: Expensive (medical record retrieval and abstraction); time-intensive.

Electronic Measures

Source: Electronic health record (EHR) data where available.

Examples: Blood pressure control, A1c testing (if EHR data feeds available).

Pros: Real-time; captures complete clinical picture.

Cons: Requires EHR connectivity; data quality issues; limited provider participation.

How to Improve HEDIS Scores

1. Data Abstraction Excellence

For hybrid measures, ensure medical record abstraction is accurate, comprehensive, and timely. Hire qualified abstractors; implement two-level QA; train on measure specifications.

2. Provider Engagement

Partner with high-volume providers to improve documentation and care processes. Share benchmark data; provide feedback on their HEDIS contribution; align incentives.

3. Member Outreach

Proactively reach members with overdue screenings. Use mail, phone, telehealth, and digital channels. Offer convenient appointment scheduling; remove barriers to access.

4. Care Coordination

Integrate HEDIS improvement into care management programs. Case managers can identify gaps and facilitate care during member interactions.

5. Technology and Automation

Deploy member identification algorithms, electronic reminder systems, and provider workflow integration. Automate reporting to reduce manual effort.

NCQA Submission Requirements

Submission Timeline

Plans must submit HEDIS data to NCQA by specific annual deadlines (typically April-May for prior-year data). Late submissions incur penalties and reputational harm.

Data Validation

All submitted HEDIS data must meet NCQA validation standards, including:

• Measure specifications compliance
• Numerator and denominator accuracy
• Data completeness checks
• Allowable exclusion documentation

Audit and Certification

Plans must have submitted data audited by certified HEDIS auditors per NCQA standards. Audit certificates must be provided with submissions.

Frequently Asked Questions