Key Takeaways:

HEDIS 2026 brings one of the more significant updates to quality reporting in recent years. Healthcare organizations that prepare strategically can transform these updates into competitive advantages.

• Seven new measures added, including tobacco screening for members aged 12+ and surgical complication tracking for members 65+.
• Two measures retired (Asthma Medication Ratio and Medical Assistance with Smoking Cessation) to reduce reporting burden.
• Complete format overhaul with new FHIR-aligned specifications affecting all measures.
• Clinical documentation quality directly impacts HEDIS performance and Star Ratings.
• Organizations achieving up to 99.9% quality and accuracy through methodical preparation and real-time monitoring.

The connection between accurate documentation, structured quality reporting, and HEDIS success has never been clearer.

Introduction

The Healthcare Effectiveness Data and Information Set (HEDIS) serves as the healthcare industry's most widely used performance measurement tool. For Medicare Advantage plans and healthcare organizations, HEDIS scores directly influence Star Ratings, reimbursement levels, and competitive positioning.

HEDIS Measurement Year 2026 introduces changes that require immediate attention. With seven new measures, two retirements, and a complete format restructuring, organizations face one of the more substantial quality reporting updates in recent years.

Organizations that begin strategic preparation now can turn these changes into competitive advantages rather than compliance burdens. The key lies in understanding what's changing, why documentation quality matters more than ever, and how to implement proven preparation strategies.

For close to 8 years, we've seen how connecting clinical documentation improvement with HEDIS quality reporting creates measurably better results.

HEDIS 2026: What’s New/Retired + Submission Readiness

NCQA introduced substantial updates across three main areas for Measurement Year 2026. Understanding these changes is critical for maintaining performance and avoiding surprises during reporting season.

HEDIS MY 2026 Updates: 7 New Measures Added

NCQA added seven new measures to the HEDIS specification, with two directly replacing retired measures and five introducing entirely new quality domains:

1. Follow-Up After Acute and Urgent Care Visits for Asthma (AAF-E) replaces the Asthma Medication Ratio and assesses whether members aged 5-64 who had an acute visit for asthma received follow-up care within 30 days. This measure focuses on improving asthma management and reducing exacerbations that lead to emergency care.

2. Tobacco Use Screening and Cessation Intervention (TSC-E) targets members aged 12 and older, measuring tobacco screening rates and cessation support. The measure expands the definition of tobacco use to include vaping, e-cigarettes, and other commercial tobacco products, reflecting current clinical realities.

3. Disability Description of Membership tracks the collection of disability status information for members aged 15 and older. This measure aims to close care gaps for persons with disabilities by improving the availability and precision of membership data.

NCQA introduced four new surgical complication measures that evaluate unplanned hospitalizations within 15 days of outpatient surgical procedures for members aged 65 and older. Each measure addresses a specific surgical category:

4. Acute Hospitalizations Following Outpatient Orthopedic Surgery (HFO) uses a risk-adjusted observed-to-expected ratio to track unplanned acute hospitalizations within 15 days of targeted outpatient orthopedic procedures. This measure identifies care coordination gaps that lead to preventable readmissions.

5. Acute Hospitalizations Following Outpatient General Surgery (HFG) uses a risk-adjusted observed-to-expected ratio to track unplanned acute hospitalizations within 15 days of targeted outpatient general surgery procedures. The measure helps identify post-operative complications or insufficient discharge planning that result in emergency department visits.

6. Acute Hospitalizations Following Outpatient Colonoscopy (HFC) uses a risk-adjusted observed-to-expected ratio to track unplanned acute hospitalizations within 15 days of outpatient colonoscopy. This measure captures complications that require inpatient admission.

7. Acute Hospitalizations Following Outpatient Urologic Surgery (HFU) uses a risk-adjusted observed-to-expected ratio to track unplanned acute hospitalizations within 15 days of targeted outpatient urologic procedures. The measure identifies complications that necessitate hospital admission.

These four measures shift the focus from simply tracking procedure volume to monitoring post-procedural outcomes and care transitions for Medicare Advantage's aging population.

HEDIS MY 2026 Updates: Two Measures Retired

NCQA retired two measures to reduce reporting burden and align with current clinical guidelines.

1. Asthma Medication Ratio (AMR) is being retired because it doesn't align with updated clinical guidelines recommending combined maintenance and reliever therapy. The measure also used a complex calculation methodology that posed barriers to accurate reporting.

2. Medical Assistance With Smoking and Tobacco Use Cessation (MSC), a survey-based measure addressing only adults, is being replaced by the more comprehensive TSC-E measure, which uses electronic clinical data and includes screening rates for both adolescents and adults.

Complete Format Overhaul

Perhaps the most consequential change is the new Fast Healthcare Interoperability Resources (FHIR)-aligned format for all HEDIS measures. This update integrates clinical evidence and general guidelines directly into measure specifications, reducing the need to reference multiple resources.

Four existing measures transitioned to Electronic Clinical Data Systems (ECDS) reporting only: Lead Screening in Children (LSC-E), Statin Therapy for Patients with Cardiovascular Disease (SPC-E), Statin Therapy for Patients with Diabetes (SPD-E), and the new measures. 

This shift reflects NCQA's ongoing commitment to digital quality measurement.

NCQA notes that these updates do not change measure intent or requirements and should not affect performance results. However, organizations may need workflow and data-capture adjustments to report accurately under the new format and ECDS transitions.

These format changes directly impact your current reporting workflows. Organizations must validate that their data extraction processes align with FHIR specifications to ensure accurate submission.

Understanding these specification changes is critical for accurate reporting. The next challenge is ensuring your chart retrieval and abstraction processes capture all qualifying documentation for measure validation.

Why Documentation Quality Matters for HEDIS Performance

Accurate clinical documentation forms the foundation of HEDIS success – yet this connection often goes underappreciated until performance gaps appear.

When documentation is incomplete or imprecise, quality measures suffer. Consider this scenario: 

• A patient with persistent asthma visits the emergency department. 
• The provider schedules a follow-up appointment for two weeks later, but the documentation doesn't capture the appointment scheduling in a way that meets the HEDIS AAF-E requirement. 
• The result? A missed quality measure that affects your Star Ratings, even though the care was delivered appropriately.

This problem compounds across your entire membership. Multiply that single missed measure by hundreds or thousands of patients, and you're looking at significant Star Rating impacts and potential revenue loss.

Organizations working with us have seen how connecting clinical documentation improvement efforts with HEDIS quality reporting creates measurable results. 

A Payor we worked with demonstrates this principle. They needed to improve their documentation accuracy to support both risk adjustment and quality measure capture. We processed more than 15,000 charts with more than 98% accuracy, resulting in a 40% increase in their RAF score.

The same principle applies to HEDIS performance. When clinical documentation accurately captures the care provided – including screening dates, intervention details, and follow-up appointments – HEDIS measures fall into place naturally. The challenge isn't delivering quality care; it's ensuring that care is documented in ways that capture quality measure criteria.

This is where strategic approaches make all the difference.

Three Strategies to Optimize HEDIS 2026 Performance

Success in Measurement Year 2026 requires a methodical approach. Here are three strategies to implement now.

Strategy 1: Conduct a Gap Analysis Now

Start by reviewing your current performance against the new 2026 specifications. Focus particularly on the measures transitioning to ECDS-only reporting, as these require different data collection workflows than hybrid or administrative-only measures.

Identify which measures put you at the highest risk. For most organizations, this includes measures where you're currently performing below the 50th percentile or where significant specification changes occurred. The new tobacco screening measure, for example, requires different workflows than the survey-based measure it replaced.

Create a prioritized list based on both the performance impact and the achievability of improvement. Some measures might have larger Star Rating impacts but require significant infrastructure changes, while others might be quick wins with the right focus.

The key is acting now. Gap analyses conducted during chart retrieval help identify documentation patterns to address before submission deadlines and inform process improvements for the next measurement year.

Strategy 2: Align CDI and HEDIS Teams

Your clinical documentation improvement specialists and HEDIS quality teams should work in lockstep, not in silos.

Ensure your documentation specialists understand how their work directly impacts quality measures. When they know that documenting a tobacco screening conversation or scheduling a follow-up appointment within specific timeframes affects HEDIS performance, they can adjust their workflows accordingly.

We provide interactive dashboards with user-friendly interfaces that offer real-time insights into productivity and performance. These dashboards help identify patterns early. If you notice that follow-up appointments for asthma aren't being documented within the 30-day window required by the new AAF-E measure, you can course-correct immediately rather than discovering the problem during your HEDIS audit.

This real-time visibility allows for continuous improvement throughout the measurement year, not just year-end scrambles to close gaps. HOM-assisted programs achieving up to 99.9% quality and accuracy in HEDIS reporting do so through measure-specific strategies rather than generic quality improvement efforts.

Strategy 3: Focus on High-Impact Measures

Not all HEDIS measures carry equal weight for your organization. Prioritize preventive screening and medication-based categories that align with your member population's needs.

We focus on NCQA-developed HEDIS measures encompassing both preventive-screening and medication-based categories. This includes measures like breast cancer screening, blood pressure monitoring, osteoporosis management in women, and statin therapy for cardiovascular disease.

Create targeted gap closure programs for your highest-impact measures. This might mean outreach campaigns for members overdue for screenings or pharmacist-led interventions for medication adherence measures. The new disability description measure, for example, requires data collection processes that differ from clinical quality measures.

With 300,000 gaps reviewed yearly and improved ratings for more than 60 primary care physicians, we've seen how targeted, measure-specific approaches deliver results. The difference lies in treating each measure as a distinct operational workflow rather than applying generic quality improvement processes.

Your HEDIS 2026 Submission Timeline

HEDIS is reported retrospectively—so in early 2026, the focus shifts from care-gap closure to chart retrieval, validation, audit readiness, and on-time submission. Timing matters as much as accuracy when managing HEDIS 2026 reporting.

Q1 2026 (Now): Retrieval and Abstraction Readiness
Accelerate provider chart chase efforts for the new measures, particularly tobacco screening documentation and surgical follow-up records. Validate that your abstraction processes correctly identify AAF-E qualifying visits and TSC-E screening encounters. Conduct documentation completeness checks against the new FHIR-aligned specifications. 

Q2 2026: IDSS Loading and Validation
NCQA releases IDSS in March. Load your data, validate measure logic against the updated specifications, and resolve discrepancies before plan-lock deadlines. Coordinate with auditors to address any flagged records. The June submission deadline requires final data validation and quality checks during this window.

Q3 2026: Post-Submission Governance
Conduct root cause analysis on missed measures and documentation gaps. Provide targeted feedback to providers on the new tobacco screening and surgical complication measures. Build in-year workflows and real-time monitoring, so you're not purely retrospective in the next measurement cycle. This quarter sets the foundation for HEDIS 2027 success.

The Bottom Line

HEDIS 2026 represents a significant shift toward digital quality measurement and more comprehensive care assessment. Organizations that treat these specification changes as opportunities for process improvement rather than compliance burdens will see better Star Ratings, improved patient outcomes, and stronger financial performance.

The connection between accurate clinical documentation and HEDIS success has never been clearer. With seven new measures, two retirements, and a complete format overhaul, thorough chart retrieval and validation now directly impact your reporting outcomes.

Organizations that accelerate their abstraction efforts and validate measure logic during Q1 will meet submission deadlines with confidence. Those who wait will face rushed validation cycles and potential measure credit loss.

Ready to optimize your HEDIS 2026 performance? Request a free audit to identify opportunities for improvement: Get in touch with us today!

FAQs

1. What are the biggest changes in HEDIS 2026?

HEDIS 2026 adds seven new measures (including tobacco screening for ages 12+ and surgical complication tracking), retires two existing measures, and introduces a new FHIR-aligned format for all measure specifications.

2. When should we start preparing for HEDIS 2026?

Organizations in Q1 2026 should focus on chart retrieval, abstraction validation, and IDSS submission readiness. NCQA releases the Interactive Data Submission System (IDSS) in March, and finalized HEDIS results and attestation are due in IDSS by mid‑June – making this quarter critical for accurate measure capture and on‑time reporting.

3. How does clinical documentation impact HEDIS scores?

HEDIS measures rely on documented evidence of care delivery. Incomplete or imprecise documentation results in missed measures, even when appropriate care was provided, directly affecting Star Ratings.

4. What is the TSC-E measure?

Tobacco Use Screening and Cessation Intervention (TSC-E) is a new measure targeting members aged 12 and older. It tracks tobacco screening rates and cessation support, including vaping and e-cigarettes.

5. How can we improve HEDIS performance while managing other priorities?

Focus on methodical preparation: conduct gap analyses early, align CDI and HEDIS teams, use real-time dashboards for monitoring, and prioritize high-impact measures based on your member population.