What does HEDIS® stand for?
HEDIS stands for the Healthcare Effectiveness Data and Information Set. It’s one of the most important tools payers across the country use to measure the quality of care their members receive. Since 1991, the National Committee for Quality Assurance (NCQA), HEDIS is a standardized measurement set that shows how well a payer is caring for its members. The performance data collected through HEDIS helps payers identify areas for improvement, track successes, and benchmark themselves against other payers nationally. Ultimately, HEDIS helps ensure members get the care and benefits they need without unnecessary costs to the payer or the member.
What is the main objective of HEDIS?
The main objective of HEDIS is to improve both measurement standards and patient care—the latter aided by avoiding excessive and unnecessary costs. By tracking the health of an overall population and reviewing treatment outcomes and procedures, HEDIS supplies an external performance benchmark payers can use to gauge quality of care, supporting performance benchmarking and quality ratings across Medicare Advantage, Medicaid, and ACA Marketplace health plans. The focus is on preventive screenings and treatment data for chronic diseases and illnesses, which payers use to confirm providers are delivering those services—ultimately lowering the overall cost of care.
HEDIS measurement standards also give both prospective and current plan members a way to compare payer performance and confirm they’re getting adequate coverage. HEDIS supports Medicare Advantage, Medicaid, Commercial, and ACA Marketplace reporting
How many HEDIS measures are there, and what domains do they cover?
As of Measurement Year 2026, HEDIS includes 93 measures across 6 domains of care, and the set is revised annually—some measures are retired, others are added or updated. The six domains are:—some measures are retired, others are added or updated. The six domains are:
- Effectiveness of Care: prevention and screening measures such as COA (Care for Older Adults), COL (Colorectal Cancer Screening), CCS (Cervical Cancer Screening), BPD (Blood Pressure Control for Patients With Diabetes), HBD (Hemoglobin A1c Control for Patients With Diabetes), and EED (Eye Exam for Patients With Diabetes)
- Access/Availability of Care: including AAP (Adults’ Access to Preventive/Ambulatory Health Services)
- Experience of Care: including member surveys such as, CAHPS® Health Plan Survey (Consumer Assessment of Healthcare Providers and Systems)
- Utilization and Risk Adjusted Utilization: including Plan All-Cause Readmissions (PCR)
- Measures Reported Using Electronic Clinical Data Systems (ECDS)
- Health Plan Descriptive Information (HPDI)
HEDIS tracks the actual care members received alongside what was ordered, to confirm they’re being served properly. Many of these measures rely on clinical information that may not be fully captured through claims data alone, making timely medical record retrieval and abstraction critical to accurate quality reporting and performance measurement.
What’s new for MY2026:
NCQA added seven measures—including four new measures evaluating unplanned hospitalizations following outpatient surgery (orthopedic, general, colonoscopy, and urologic procedures), a new Disability Description of Membership measure, and an ECDS-based tobacco use screening and cessation measure that replaces the retired survey-based smoking cessation measure. NCQA also moved the technical specifications to a new format aligned with the FHIR® data standard, continuing its multi-year shift toward richer clinical data evidence and digital quality measurement.
A closer look at AAP
Within the Access/Availability of Care domain, AAP (Adults’ Access to Preventive/Ambulatory Health Services) evaluates whether adult enrollees had a preventive or ambulatory visit with a physician. This measure helps health plans assess how many members are receiving preventive services or counseling. By analyzing AAP data, health plans can spot correlations between preventive care, addressing acute issues, and identifying chronic conditions—giving valuable insight into the quality of care patients receive.
How is HEDIS data collected?
HEDIS data is derived from multiple sources, allowing health plans to evaluate quality, utilization, access, and member experience across their populations. Historically, reporting has relied on administrative, hybrid, and survey data, while newer measures increasingly incorporate electronic clinical data sources through NCQA’s Electronic Clinical Data Systems (ECDS) framework.
- Administrative data: claims for hospitalizations, medical office visits, procedures, and pharmacy fills.
- Hybrid data: used when a measure needs more clarification than claims alone provide; administrative data is combined with information pulled directly from the patient’s medical record.
- Survey data (CAHPS®): the Consumer Assessment of Healthcare Providers and Systems (CAHPS), a survey program originally developed under the Agency for Healthcare Research and Quality (AHRQ), captures self-reported patient experience through a post-encounter satisfaction survey.
- Electronic Clinical Data Systems (ECDS): Increasingly, HEDIS measures are reported using data from electronic health records (EHRs), health information exchanges, clinical registries, care management systems, and other interoperable clinical data sources. NCQA continues to expand ECDS reporting as part of its broader digital quality measurement strategy
How many people does HEDIS affect?
HEDIS has grown substantially in reach. More than 235 million people are now enrolled in health plans that report HEDIS results and HEDIS is used by more than 90% of America’s health plans. That scale is exactly why accurate documentation matters: providers need to deliver great care and document it correctly, since a service that isn’t captured in the data effectively didn’t happen for measurement purposes.
Electronic health records (EHRs) help prevent gaps caused by improper recording or storage of patient data. To perform well on HEDIS, providers need to:
- Understand what each measure is asking for
- Collaborate with patients to close specific gaps in care
- Ensure medical coding is accurate and complete
- Respond to medical record requests promptly and completely
Payers rely on this data to achieve strong HEDIS scores, which directly affects reimbursement rates, incentive payments, and the overall quality of care delivered to members.
The payer path vs. the provider path
For payers: HEDIS performance depends on how quickly and completely providers return the records and data needed for each measure. Faster, cleaner data exchange means more accurate rates, less abstraction burden during hybrid measure season, and stronger performance heading into NCQA’s Health Plan Ratings each fall. HEDIS success is no longer about measuring care. It’s about accessing the clinical data necessary to prove it. MRO helps health plans bridge that gap by connecting disparate provider data sources and transforming medical record retrieval into a strategic asset across Medicare Advantage, Medicaid, and ACA quality programs.
For providers: HEDIS performance depends on documentation discipline and coding accuracy at the point of care, plus the ability to respond to payer record requests without disrupting clinical operations. Providers who standardize how they capture and release records are consistently the ones with the fewest last-minute scrambles during HEDIS season.
MRO plays a role on both sides—streamlining how payers and providers exchange the information needed for HEDIS data collection, so it comes back quickly, accurately, and in the format each measure requires.
MRO’s unique position at the intersection of payers and providers enables health plans to access high-quality clinical data while maintaining positive provider relationships. As quality measurement expands across Medicare Advantage, Medicaid, and ACA Marketplace populations, organizations that can efficiently acquire, abstract, and operationalize clinical data will be best positioned to improve quality outcomes, enhance member care, and achieve long-term program success.
Get HEDIS data back faster
Strong HEDIS scores start with strong data exchange between payers and providers. MRO helps close the gap—returning the records and information each measure requires quickly, accurately, and in the format payers need.
Contact MRO to talk about your HEDIS data exchange needs.
Frequently Asked Questions
Is HEDIS the same as Medicare Star Ratings?
No, but they’re closely related. CMS uses a subset of HEDIS clinical measures as part of the Medicare Advantage Star Ratings calculation, so HEDIS performance directly influences a plan’s Star Rating.
Who has to report HEDIS?
Reporting isn’t legally mandatory for every plan, but it’s effectively required for NCQA accreditation, and CMS requires it for Medicare Advantage plans and ACA Marketplace issuers. More than 90% of U.S. health plans report HEDIS data.
How often do HEDIS measures change?
Annually. NCQA runs a public comment process each year and releases an updated measure set for the upcoming Measurement Year, typically finalizing technical specifications each spring.
