Advent Tip: Secure additional data for these measures, including immunization registry data for CIS and IMA, historical CCS exclusion and numerator data, and vision data for EED. Rates will likely dip but by planning ahead you can lessen the impact.
HEDIS MY2025 Considerations
June 18, 2025
With the ink barely dry on HEDIS MY2024, planning for HEDIS MY2025 is already underway. Advent’s HEDIS webinar series will start up soon. In the meantime, here are some changes to keep in mind.
1. Medical record review option eliminated for 4 longtime hybrid measures.
- Childhood Immunization Status (CIS)
- Immunizations for Adolescents (IMA)
- Cervical Cancer Screening (CCS)
- Eye Exam for Patients with Diabetes (EED)
2. New data element – Breast Imaging Reporting and Data System (BI-RADS) assessment codes – needed for the 2 new mammogram-related measures. BI-RADS-related value sets include SNOMED CT codes as well as RadLex radiology lexicon. RadLex is a comprehensive set of radiology terms for how medical imaging is described, reported, and analyzed.
Advent Tip: Continue to investigate where this data might reside for your organization, how you can secure it, and what internal changes are needed to use it for HEDIS reporting. Although these first-year measures will not be publicly reported, your ability to report them next year is largely dependent on how far you get this year.
3. Change in race and ethnicity data source reporting requirements.
Reporting on the source of race and ethnicity data will only be required for the Race/Ethnicity Diversity of Membership (RDM) measure. Race and ethnicity stratifications (RES) will still be required for other measures; however, the source of that data will not be reported at the measure-level.
Data source reporting for RDM has been condensed to the following 4 categories.
- Direct: Race/ethnicity value is known, and the source is direct (e.g., self-reported, CMS and state data sources).
- Imputed: Race/ethnicity value is known but is collected through an alternate data source (e.g., geo-coding, surname analysis).
- Unknown: Race/ethnicity value is known but the source is not.
- No Data: Race/ethnicity value is not known.
Advent Tip: Submit your revised RES mapping early for auditor review. Also, keep tracking down direct data sources; NCQA continues to push forward a threshold for “data collected directly from members.” If you have not reported the RDM measure in the past, expect to report it for HEDIS MY2025 since this will be the only measure reporting on the source of race and ethnicity data.
As always, when in doubt check in with your auditor. They can provide more insights into these and other changes for HEDIS MY2025. And remember, the earlier you get started, the better prepared you will be.
Contact us at
info@adventadvisorygroup.com to see how we can help.
Advent Advisory Group Insights
NCQA has opened the 2026 HEDIS® Public Comment period, running from February 13 through March 13, 2026.
CMS has released its CY 2027 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies.
The CMS 2026 Program Audit Annual Updates bring several important changes that healthcare sponsors must address to stay compliant. These updates affect various aspects of the audit process, from condition classifications to new requirements for validation audits.
Aside from the usual updates to the audit timeline and other wording changes, this year’s HEDIS audit manual includes several changes of significance.
The Advent team had the opportunity to attend the NCQA Health Innovation Summit, where healthcare leaders and innovators came together to explore the next phase of digital quality measurement and value-based care.
HEDIS is shifting. Stars are flattening. Advantage goes to plans that act now. After several consecutive years of declines, the average Medicare Advantage (MA) Star Ratings are essentially flat for 2026.
As California leaders assess the sweeping implications of these proposed changes, Advent Advisory Group is helping health plans evaluate exposure, model financial impacts, and prepare operational strategies across Medicare, Medi-Cal, and Commercial lines.
The 2025 NCQA Health Plan Ratings are out. For health plans, these results are more than just numbers — they’re a public reflection of quality, experience, and performance.
CMS recently published its annual Part C and Part D Program Audit and Enforcement Report. The report provided recommendations and guidance for Sponsors to consider when preparing for future CMS Program Audits.
Advent’s HEDIS 2026 webinar series kicked off last month with Optimizing Clinical Data Quality, a presentation focused on common challenges with supplemental clinical data. Key takeaways include the following: Transition in Data Collection: The shift from manual data collection to digital HEDIS reporting has increased the focus on clinical data over claims data. NCQA’s planned elimination of the hybrid reporting method has added urgency to this transition, driving plans to acquire more electronic clinical data and adapt to year-round ingestion. Challenges with Clinical Data: The presentation highlighted several challenges to the acquisition of supplemental clinical data, including data timing, completeness, and accuracy. Issues such as short turnaround times, missing biometric values, and incorrect coding have impacted the useability of these additional data sources for HEDIS reporting. Tips for Navigating the Transition: Plans can navigate this transition by starting early with clinical data validation, engaging with IT departments, exploring vendor’s reports and supportive capabilities, and building executive leadership buy-in.
