MY 2026: Breaking down the latest HEDIS Technical Specifications

As health plan leaders prepare for the next cycle of quality reporting, the HEDIS^® Measurement Year (MY) 2026 Technical Specifications represent a significant shift for measure design and reporting requirements. The National Committee for Quality Assurance (NCQA) continues to refine HEDIS measures to better reflect the evolving landscape of healthcare quality assessment, introducing seven new measures for MY 2026 alongside meaningful updates to existing ones. These changes affect risk-adjusted outcomes, electronic clinical data system (ECDS) reporting, and member descriptive information.

Understanding these updates is essential for plans to ensure compliance and maximize performance. We compared the MY 2026 specifications against the materials that NCQA proposed as part of the Public Comment period to help pinpoint adjustments from public feedback and submitted several questions regarding the measures to share additional insights. Here, we offer a structured breakdown of confirmed changes, clarifications, and specific strategies to enable plans to prepare for MY 2026.

New for MY 2026

NCQA is introducing four new risk-adjusted and two new ECDS measures to begin reporting in 2026, along with a new health plan descriptive information measure. The risk-adjusted measures, which were originally proposed by NCQA in their February 2024 Public Comment, are as follows:

• HFC: Acute Hospitalizations Following Outpatient Colonoscopy is the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations shortly after an outpatient colonoscopy procedure. NCQA refined the exclusionary criteria for this measure from the original proposed version, removing exclusions for a diagnosis of pregnancy or perinatal conditions and separating GI endoscopy and secondary colonoscopy exclusions. We received additional clarification confirming that hospitalizations on the day after an outpatient colonoscopy would exclude the colonoscopy from the denominator, whereas hospitalizations in the 2–15 days after the colonoscopy would qualify for the numerator.
• HFG, HFO, HFU: Acute Hospitalizations Following Outpatient General Surgery, Orthopedic Surgery, and Urologic Surgery are similar to HFC and measure the risk-adjusted ratio for unplanned acute hospitalizations following outpatient general surgery, outpatient orthopedic surgery, and outpatient urologic surgery respectively. All three share the same denominator and numerator exclusion criteria, with updates to remove exclusions for pregnancy and perinatal conditions.

The two new ECDS measures include:

• AAF-E: The Follow-Up After Acute and Urgent Care Visits for Asthma measure replaces the administrative Asthma Medication Ratio (AMR) measure, which will be retired. This measure captures whether appropriate follow-up occurred after an urgent care, ED visit, acute inpatient stay, or observation discharge for asthma. The finalized version of the measure includes expanded eligible events, allowing the eligible asthma diagnosis to be in any claim position rather than just the principal position. Denominator ED and urgent care events can now be excluded if they are followed by a stay with any admission diagnosis on or within 30 days, with exclusions for acute respiratory failure and emphysema being removed. Additionally, NCQA added a diagnosis of asthma requirement for the follow-up visit to be numerator compliant.
• TSC-E: The Tobacco Use Screening and Cessation Intervention measure replaces the CAHPS^® survey measure Medical Assistance with Smoking and Tobacco Use Cessation. This measure evaluates the percentage of people 12 and older who were screened for tobacco use during the measurement year, as well as the percentage of identified tobacco users who received cessation intervention in the measurement year or 180 days prior. Notable updates include the addition of palliative care as an exclusion and the removal of ICD-10 codes for tobacco use identification. The cessation intervention denominator should include anyone with at least one positive tobacco use response, regardless of the presence of any negative tobacco use responses during the eligibility timeframe. NCQA confirmed upcoming changes for reporting data elements including removing Benefit metadata, limiting exclusion reporting to the Tobacco Use Screening metric, and adding a Data Elements for Reporting table for Medicare in future technical specification updates.

The new health plan descriptive information measure DDM, titled Disability Description of Membership, evaluates the number of health plan members who identify as disabled. Compared to the public comment measure, the finalized DDM removes the 15 or older age requirements and secondary disability type stratification, focusing solely on capturing disabled versus not disabled status across the entire plan population. NCQA also added a new note indicating that if there is a discrepancy in disabled status between different data sources, plans should prioritize the disabled status for a member to not undercount the disabled population. For members who respond to a disability questionnaire as “declined” or “prefer not to answer,” these members should be classified as missing disability status from the “no data” status source.

Confirmed changes for MY 2026

Beyond the new measures, NCQA has made broad updates to existing HEDIS specifications and reporting elements.

One major change includes adding, renaming, and removing reportable data elements across nearly every HEDIS measure, as shown in Figure 1. Notably, the initial population data element has been added to many measures, a new race category of Middle Eastern or North African has been split out from the White race category, and ECDS measures have removed all source systems of record breakouts.

Reporting type	MY 2026	MY 2025	Changes
Administrative and hybrid	Initial Population	−	Added
	Exclusions	Exclusion Admin Required	Renamed
	Denominator	Eligible Population Denominator (Hybrid)	Renamed and Removed
	Numerator By Admin Denom	Numerator By Admin Elig	Renamed
Race and ethnicity	Middle Eastern Or North African	−	Added
	Native Hawaiian Or Pacific Islander	Native Hawaiian Or Other Pacific Islander	Renamed
	Denominator	Eligible Population Denominator (Hybrid)	Renamed and Removed
ECDS	−	Initial Population By EHR Initial Population By Case Management Initial Population By HIE Registry Initial Population By Admin	Removed
	−	Exclusions By EHR Exclusions By Case Management Exclusions By HIE Registry Exclusions By Admin	Removed
	−	Numerator By EHR Numerator By Case Management Numerator By HIE Registry Numerator By Admin	Removed
Risk	Non Outlier Person Count	Non Outlier Member Count	Renamed
	Outlier Person Count	Outlier Member Count	Renamed
	Person Count	Member Count	Renamed

Figure 1. NCQA updates to reportable data elements.

Deletions from the MY 2026 specifications include the removal of domain-level general guidelines as components are now being incorporated directly into applicable measure specifications. The ECDS domain has retired the source system of record data prioritization hierarchy, resulting in ECDS measures having no specified data prioritization requirements, as the general guideline for Supplemental Data prioritization does not apply to ECDS measures. NCQA also removed various medication tables and appendices from the Volume 2 specifications, directing readers to reference the separate Medication List Directory spreadsheet instead. A publicly available Excel workbook has replaced the Logical Measure Groupings appendix.

Four measures are transitioning to ECDS reporting, including:

• BPD-E: The Blood Pressure Control for Patients with Diabetes measure is not yet replacing its administrative and hybrid reported counterpart BPD—retaining both measures in the MY 2026 specifications. The key areas where BPD-E will differ from the existing BPD measure include the ability for BPD-E to utilize supplemental diabetes diagnoses or medications for denominator eligibility with no separate data elements for administrative and supplemental numerator compliance, merging compliance in a single numerator data element.
• LSC-E: The Lead Screening in Children measure replaces the administrative and hybrid LSC measure, which is retired in MY 2026. The primary differences for LSC-E are the loss of hybrid reporting methodology and the merging of administrative and supplemental compliance into a single numerator data element.

• SPC-E and SPD-E: The Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes measures are both also transitioning to ECDS reporting only, retiring their administrative reporting counterparts SPC and SPD. These measures finalized the majority of their proposed changes from the 2025 public comment period except for the upper age limit expansion of the SPC-E measure. These two measures will now be able to utilize supplemental data to identify eligible members with cardiovascular disease and diabetes for their denominators.

Several existing HEDIS measures underwent changes for MY 2026. These include:

• AIS-E: The Adult Immunization Status measure has added the proposed COVID-19 numerator from the public comment but changed the age requirements from 19 and older to now be for 65 and older.

• ABX: The Antibiotic Utilization for Respiratory Conditions measure now includes deceased exclusion, aligning it with the remaining Utilization well-child measures W30 and WCV.

• BCS-E: The Breast Cancer Screening measure removed the exclusion option for Unilateral Mastectomy found in clinical data with a bilateral SNOMED qualifier value, but the exclusion for unilateral mastectomy with a bilateral CPT modifier remains.

• FMC: The Follow-up After ED Visit for People with Multiple High-Risk Chronic Conditions measure now prohibits a gap in continuous enrollment on the date of the eligible ED visit.

• FUI: The Follow-Up After High-Intensity Care for Substance Use Disorder measure allows numerator events to have a substance use diagnosis in any claim position instead, as well as a peer support services numerator option. NCQA did not remove the pharmacotherapy numerator option.
• HPC: The risk measure Hospitalization Following Discharge from a Skilled Nursing Facility removed the numerator exclusion for a principal diagnosis of pregnancy on the discharge claim.
• OED: The Oral Evaluation, Dental Services measure has changed the continuous enrollment timeframe from the second half of the measurement year to 180 days of enrollment anytime during the measurement year.

• SNS-E: The Social Needs Screening and Intervention measure has value set changes for both denominator and numerator criteria, incorporating HCPCS G0136 codes into the screening numerators and ICD-10 Z codes into the intervention denominators. Assessment CPT codes from the intervention numerators and age requirement of 66 and older for the I-SNP and long-term institution (LTI) exclusion have been removed, allowing Medicare members of any age enrolled in an I-SNP or LTI to be excluded.

Strategies to improve measure reporting

Proactive data mapping, process adjustments, and early engagement with internal teams and vendors is critical for health plans to build a strong foundation. Here are a few steps your organization can take to help prepare.

• Locate internal sources of disability status data. As this data is not captured through existing claims using value sets, plans will need to work internally to capture this data and create additional data mapping efforts.
• Evaluate EHR data for tobacco use screenings. Confirm that tobacco usage screenings and responses are included in data vendor EHR feeds and accurately mapped to LOINC and SNOMED codes.
• Adjust race collection and mapping. Ensure Middle Eastern and North African races are separately documented and update code mapping for “Some Other Race” from the previous HL7 “OTH” code to the new CDCREC 2131-1 code.
• Analyze COVID-19 vaccine data availability. Review immunization data sources to confirm COVID-19 vaccine documentation for members aged 65 and older.
• Review supplemental data impact to denominators. For measures transitioning to ECDS, assess how supplemental diabetes and cardiovascular data may expand eligible populations.
• Plan for lead screening data capture. With hybrid reporting retired, ensure that supplemental lead screening data is mapped to appropriate value set codes.

By understanding the confirmed new measures, key updates since the public comment period, and noteworthy modifications to existing measures, quality leaders can position their organizations for success.

Register for the last installment in our series as we tackle the 2026 Star Ratings results on October 23.

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