What is HEDIS (Healthcare Effectiveness Data and Information Set)?
Definition
The Healthcare Effectiveness Data and Information Set (HEDIS) is the standardized health-plan performance measurement set developed and maintained by the National Committee for Quality Assurance (NCQA). It is the dominant quality measurement framework in US health insurance, used by more than 90% of health plans across Medicare Advantage, Medicaid managed care, and the commercial market. HEDIS measure performance drives NCQA plan accreditation and is a primary input into the CMS Medicare Advantage Star Ratings program.
Structure and stewardship
NCQA, a nonprofit organization founded in 1990, is the measure steward — it develops, tests, refines, and retires HEDIS measures through a multi-stakeholder process involving health plans, clinicians, researchers, and consumer representatives. The current measure set spans roughly 90 measures grouped into domains including effectiveness of care (preventive screening, chronic disease management, behavioral health), access and availability of care, patient experience of care, utilization and risk-adjusted utilization, and health-plan descriptive information.
Measures are specified at the technical level — eligible population, numerator events, exclusions, allowable data sources — so that performance is comparable across plans. NCQA publishes annual technical specifications updates, and plans report HEDIS data annually through NCQA’s Interactive Data Submission System.
Reporting cycle and audit
HEDIS reporting follows an annual cycle. Plans collect data on measurement-year activity (the calendar year being measured), submit reports the following spring, and receive audited and published results in summer. NCQA-certified auditors validate plan submissions before public release. The audit requirement is a defining feature of HEDIS — it is one reason plans can be compared on a like-for-like basis, and it is why HEDIS performance carries weight with CMS and state Medicaid agencies.
HEDIS and Medicare Advantage Star Ratings
A substantial portion of the CMS Medicare Advantage Star Ratings — the rating program that determines plan-level quality bonus payments and serves as the consumer-facing plan quality signal — is derived from HEDIS measure performance. Medicare Advantage Star Ratings combine HEDIS measure performance with CAHPS patient-experience measures, Health Outcomes Survey results, and Part D measures, but HEDIS measures contribute meaningfully to the composite rating. Plan revenue is directly affected by Star Ratings — plans rated 4 stars and above receive a quality bonus payment, currently 5% of the county benchmark rate, which materially affects plan economics and consumer-facing premium pricing.
How APCM activities improve HEDIS performance
APCM, including its CY2026 behavioral health add-on codes, reimburses care-management activities that map directly onto multiple HEDIS effectiveness-of-care measures:
- Controlling High Blood Pressure (CBP) — Documented BP control in patients with hypertension. APCM care-management workflows include BP monitoring, medication adherence support, and follow-up.
- Comprehensive Diabetes Care / Glycemic Status Assessment — A1c control and screening cadence. APCM panel-management workflows surface patients due for A1c testing and support adherence to diabetes care plans.
- Antidepressant Medication Management (AMM) — Acute-phase and continuation-phase adherence to antidepressant therapy. The CY2026 APCM-aligned BH add-on codes (G0568-G0570), delivered through integrated behavioral health workflows, support exactly the medication-management activity AMM measures.
- Depression Screening and Follow-Up for Adults (DSF) — Screening using a standardized instrument and documented follow-up. BHI workflows under APCM include PHQ-9 screening and registry-based follow-up.
- Initiation and Engagement of Substance Use Disorder Treatment (IET) — Timely initiation and engagement after an SUD diagnosis. Integrated BH care management is the model under which these activities scale within primary care.
- Follow-Up After Hospitalization for Mental Illness (FUH) — Timely outpatient follow-up after mental health hospitalization. Care-management transitions workflows support this measure.
The fit is direct because both frameworks reflect the same underlying clinical priorities: identify the at-risk population, screen systematically, treat to target, follow up reliably. APCM reimburses the work; HEDIS measures the result.
HEDIS in the value-based-care landscape
For a primary-care practice, HEDIS performance is relevant insofar as the practice contracts with Medicare Advantage plans, Medicaid managed-care plans, or commercial plans that flow HEDIS-tied incentives to providers. Many such contracts include quality bonus payments contingent on the practice’s contribution to plan HEDIS performance. APCM-driven care-management activity, particularly with the BH add-ons, supports these contract-level quality incentives without requiring a separate workflow.
Primary sources
- National Committee for Quality Assurance (NCQA). HEDIS Technical Specifications — annual publications, current measurement year.
- Centers for Medicare & Medicaid Services. Medicare Advantage and Part D Star Ratings Technical Notes — annual publications.
- NCQA Health Insurance Plan Ratings publications.
- USPSTF recommendations underlying preventive-care HEDIS measures.
Related concepts
For the broader payment shift HEDIS supports, see What is value-based care?. For the Medicare quality program that overlaps with HEDIS measures, see What is the Quality Payment Program?. For ACO programs whose quality measures harmonize with HEDIS, see What is the MSSP? and What is ACO REACH?. For APCM and the behavioral health add-ons that support HEDIS behavioral-health measures, see What is APCM? and What is BHI?. For strategic context, see The APCM Opportunity.