December 22, 2025 | CQL and FHIR, Digital Quality Transformation, Star Ratings, Uncategorized, Year Round Prospective HEDIS®
2025 Year In Review: HEDIS and Star Ratings
Quality Measurement is in the midst of a tidal wave of change, even though you really wouldn’t know it from the measure stability we’ve experienced over the past several years. However, while the measure specs may stay the same, the swirl of change can be felt everywhere else, from fundamental program economics to underlying technology. And all of this is preparing us for the 2030 target. As we prepare to close out MY25, let’s review some of these major developments with an eye toward where we are headed.
Rebecca Jacobson, MD, MS, FACMI
Co-Founder, CEO, and President
January 29, 2025
Completion of NCQA MY24 Measure Set
NCQA released the remaining six digital measures to complete the entire MY24 set. This was the first year in which all digital measures were available. In June 2025, NCQA released the MY25 measure set and we are expecting MY26 measures to be released earlier in the year. Perhaps just as importantly, we are seeing significant improvement in CQL measures, which are more consistent and designed to run faster. The FHIR HEDIS Implementation Guide is also stabilizing. And we understand that validation packages will be released at the same time as the measure packages starting next year. This all adds up to a groundbreaking change starting next year, as Astrata and other digital HEDIS® vendors can provide our health plan customers with HEDIS® engines that run prospectively in the latest measurement year.
June 23, 2025
HHS and CMS Roundtable with Insurers
As a precursor to a number of aligned initiatives, CMS and HHS met with major insurers in June of this year who pledged to work toward key reforms including cutting red tape, accelerating care decisions, and enhancing transparency for patients and providers. Although the stated goals do not directly impact quality measurement, the announcements that have followed regarding interoperability and aligned networks do have the potential to significantly impact quality measurement for the better. Stay tuned to what your organizations are pledging as CMS looks to reduce the friction and improve the transparency of core health plan operations.
July 31, 2025 and September 26, 2025
CMS Interoperability Framework and Health Tech Ecosystem
Hard on the heels of the June roundtable, CMS announced the Health Technology Ecosystem and the CMS Interoperability framework. The CMS Health Technology Ecosystem (a.k.a. the CMS Digital Health Ecosystem) is a collaborative government and industry effort to modernize and connect the US healthcare data landscape. It consists of several foundational elements including the CMS Interoperability Framework, CMS-Aligned Networks, and the National Provider Directory & Identity Infrastructure. The Interoperability Framework is an effort to use existing interoperability building blocks to fast-track a set of working “aligned networks” sharing information and enabling patient-facing apps to address chronic diseases and improve patient experience.
These efforts are currently voluntary and pledge-based. But be careful before you write this off as something you can safely ignore. This standards-based program will likely play an important role in future CMS initiatives that your organizations will need to adopt. If you don’t pay attention now, you may find yourself struggling to meet future regulatory requirements or revenue imperatives.
Source:
CMS Health Technology Ecosystem
CMS Interoperability Framework
September 17, 2025
NCQA names Dr Vivek Garg as President and CEO of NCQA
After four decades of groundbreaking leadership, NCQA President and CEO Peggy O’Kane passed the torch to Dr. Vivek Garg who will take the reins in early 2026. Dr. Garg’s distinguished background includes significant time in the healthcare trenches. This is an extremely important time for NCQA and the quality community as a whole, and we look forward to hearing Dr. Garg’s vision.
Source: NCQA Names Dr. Vivek Garg as President and Chief Executive Officer
November 28, 2025
CMS 2027 MA and Part D Proposed Rule Released
Another bellwether of change is the 2027 Proposed Rule, released in November 2025. CMS proposed to remove 12 administrative measures from Parts C and D. What’s important here is that many of these administrative measures saw strong performance among a wide range of health plans. Removing them complicates the “math path” to 4 stars. Experts at Milliman have modeled the measure changes under the current policies and observed that the new program will likely reduce Star ratings and associated revenue while increasing overall volatility of the Star Ratings.
Two other important changes in the 2027 Proposed Rule: instead of implementing the health equity index (rebranded as EH04), we expect to see the continued use of the Reward Factor in 2027. Among HEDIS® measures, EED (Eye exam in Diabetics) may be retired, and Depression Screening and Follow-Up could be added.
Several key trends are evident here. First, expect continued pressure on MAOs to focus on clinical outcomes, preventive care, and member health. As measurement becomes digital, and plans have access to more data, this trend can be expected to accelerate. Second, the proposed rule continues to build on the theme of regulatory simplification and reduced measure burden. But reducing measure burden can increase financial burden. With the removal of these more stable administrative measures, remaining measures (including HEDIS® measures) are now much more valuable in terms of impact on your rate. Third, forward-thinking health plans must prepare for increased rating volatility which can impact incentive programs. That means nailing down performance on measures that have been table-stakes before, and doing so as early in the year as possible.
Source: 2027 Proposed Rule by HHS & CMS
December 1, 2025
CMS Access Program announced
The announcement of the new CMS Access model (Advancing Chronic Care with Effective, Scalable Solutions) on December 1st was met with significant interest across the industry. The model tests an outcome-aligned payment approach in traditional Medicare. This program specifically advances the use of digital tools for providers along with other services that have not previously been paid for under fee-for-service Medicare. Disease conditions will include depression, diabetes, musculoskeletal pain, and hypertension. It includes both upside and downside to providers. Again, this may not seem directly tied to healthcare quality measurement on the surface. But in fact, the interoperability and data maturity needed to succeed in this program is likely to bleed over quickly to quality measurement.
Source: CMS ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model