Breaking down NCQA’s proposed changes for HEDIS Measurement Year 2020

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The National Committee for Quality Assurance (NCQA) is accepting comments through March 13 on proposed changes for next year’s HEDIS® season, Measurement Year 2020 (MY 2020), from health plans and other stakeholders. Jamison Gillitzer, product manager for Cotiviti’s quality improvement solutions, summarizes the important details for plans that report HEDIS data.

Changes to existing measures

NCQA is proposing several changes to measures related to well-child visits, high-risk medication use, and depression screening, among many others.

Measure Name

Summary of Proposed Changes

Well-Child Visits in the First 15 Months of Life (W15)

  • Remove hybrid reporting as medical record review has had a lower impact on performance over time
  • Add 15–30 months age range to incorporate children previously not captured
  • Remove performance rates for 0–5 visits and provider type requirement
  • Rename to Well-Child Visits in the First 30 Months of Life

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)


Adolescent Well-Care Visits (AWC)

  • Combine the two measures and rename to Child and Adolescent Well-Care Visits
  • Remove hybrid reporting
  • Add 7–11 year age range and split adolescent age range into two age groups

Emergency Department Utilization (EDU)

  • Remove ED visits that convert to observation stays from the numerator to bring measure into alignment with other risk-adjusted utilization measures
  • Classify members who utilize ED with high frequency as outliers and remove them from risk-adjusted ED rate
  • Add a new indicator reporting the rate of outliers among the plan population to promote transparency in reporting members who are excluded due to outlier status

Use of High-Risk Medications in Older Adults (DAE)

  • Add new measure rate to include antipsychotics and benzodiazepines and their corresponding diagnosis-based exclusions
  • Remove 90-days supply criterion for non-benzodiazepine hypnotics to alleviate concerns of unintended consequences of prescribing benzodiazepines in place of them
  • Extend continuous enrollment from one to two years to build in a look-back period
  • Change assessment of numerator compliance from specific medications to medication class
  • Add a total rate to provide a high-level overview of high-risk medication use

Transitions of Care (TRC)

  • Revise “one medical record” requirement to also allow “other information accessible” to the PCP or care provider (e.g., shared EMRs)

Controlling High Blood Pressure (CBP)

  • Restructure the denominator to allow a minimum of six months for interventions to help control a member’s blood pressure during the measurement year

Follow-Up After Hospitalization for Mental Illness (FUH)

  • Allow follow-up visits in behavioral healthcare settings to count in the numerator without requiring a specific provider type
  • Allow community mental health centers (CMHC) and certified community behavioral health clinics (CCBHC) to meet the HEDIS definition of “mental health providers”

Adult Immunization Status (AIS)

  • Remove numerator requirements for pneumococcal immunization status to reflect that pneumococcal conjugate vaccine (PCV13) is no longer routinely recommended for adults 65 and older

Unhealthy Alcohol Use Screening and Follow-Up (ASF)

  • Revise exclusion timing to only exclude members who have an alcohol use disorder (AUD) diagnosis in the prior year, not the measurement year

Depression Screening and Follow-Up for Adolescents and Adults (DSF)

Prenatal Depression Screening and Follow-Up (PND)

Postpartum Depression Screening and Follow-Up (PDS)


  • Raise threshold for identifying members who screen positive for depression to help target resources to those in most need of follow-up care

New measures being introduced

NCQA proposes three new measures for MY 2020, two of which replace measures being retired.

Measure Name


Cardiac Rehabilitation (CRE)

“The percentage of members 18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, heart and heart/lung transplantation or heart valve repair/replacement.”

This includes three rates:

  • Initiation: % of members who attended two more rehabilitation sessions following a qualifying event
  • Engagement: % of members who attended 12 or more rehabilitation sessions within 90 days of a qualifying event
  • Achievement: % of members who attended 36 or more sessions within 180 days of a qualifying event

Kidney Health Evaluation for Patients with Diabetes (KED)

“The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR), during the measurement year.” Replaces Comprehensive Diabetes Care (CDC)–Medical Attention for Nephropathy.

Osteoporosis Screening in Older Women (OSW)

“The percentage of women 65–75 years of age who are screened for osteoporosis.” Replaces Osteoporosis Testing in Older Women (OTO).

Measures being retired

NCQA proposed to retire four measures and two measure indicators for Comprehensive Diabetes Care (CDC). These retirements would be effective MY 2020 with the exception of Annual Dental Visit (ADV), which would not be effective until MY 2022.

Measure Name

Rationale for Retiring Measure

Annual Dental Visit (ADV)

  • Sets a low threshold and focuses on access to dental care versus quality

Adult BMI Assessment (ABA)

  • Less relevant as automatic calculation of BMI in EHR systems is standard practice
  • Changes to ICD-10 coding guidelines
  • Average Medicare performance has nearly topped out

Medication Management for People with Asthma (MMA)

  • New recommendations for controller combination therapy
  • Recent evidence suggesting measure not coordinated with improved outcomes

Children and Adolescents’ Access to Primary Care Practitioners (CAP)

  • Proposed revisions to current well-child measures make this obsolete

Comprehensive Diabetes Care (CDC)–Medical Attention for Nephropathy indicator

  • Feedback that this indicator is not precise enough to meet the needs of kidney health evaluation as an aspect of diabetes management
  • Replaced by proposed KED measure

Comprehensive Diabetes Care (CDC)–HbA1c Control (<7.0%) for a Selected Population indicator

  • Concerns about large burden on plans reporting CDC measure outweigh benefit of indicator
  • Other indicators already meet intent for quality measurement of HbA1c testing and control

Cross-cutting exclusion

Noting that “quality measures designed for a general population may not be clinically appropriate or a priority” for those receiving palliative care, including certain opioid measures, NCQA proposes to exclude members receiving palliative care across the following 13 measures:

  • Risk of Continued Opioid Use
  • Use of Opioids at High Dosage
  • Potentially Harmful Drug Interactions in Older Adults
  • Use of High-Risk Medications in Older Adults
  • Breast Cancer Screening
  • Cervical Cancer Screening
  • Colorectal Cancer Screening
  • Osteoporosis Screening in Older Women
  • Comprehensive Diabetes Care
  • Controlling High Blood Pressure
  • Osteoporosis Management in Women Who Had a Fracture
  • Statin Therapy for Patients With Cardiovascular Disease
  • Statin Therapy for Patients With Diabetes

Health Plan Descriptive measures

With the goal of “simplifying reporting and reducing undue customer burden while ensuring that reported data is meaningful,” NCQA is seeking public comment on the value of these six descriptive measures:

  • Enrollment by Product Line (ENP)
  • Enrollment by State (EBS)
  • Language Diversity of Membership (LDM)
  • Race/Ethnicity Diversity of Membership (RDM)
  • Total Membership (TLM)
  • Board Certification (BCR)

NCQA asks health plans to offer input on whether they use them for their own accountability, quality improvement, or payment initiatives, and which measures are useful.

Timeline changes

While NCQA is not seeking public comment on these changes, the organization is shifting two dates in its annual publication and certification deadline schedule to release complete measure specifications nearly a full year earlier than its previous schedule, as summarized below. In tandem with these changes, vendors will now have more time between when specifications are released and the final certification deadline.


MY 2020 Release Date (current year)

MY 2021 Release Date (transition year)

MY 2022 Release Date (future years)

Volume 1 (Narrative) and Volume 2 (Technical Specifications)

July 1, 2020

July 1, 2020 (combined with MY 2020)

August 1, 2021

Volume 2 Technical Update

October 1, 2020

March 31, 2021

March 31, 2022

Vendor Certification

February 15, 2021

October 1, 2021

July 1, 2022

Time to comment

Ready to weigh in? Read NCQA’s full description of all proposed changes and follow the directions on this page by 11:59 pm ET on Friday, March 13, 2020. 

How does the HEDIS software measure certification process work, and how does it impact a health plan's processes when a vendor has to recertify mid-season? Watch our recent video as we explain the basics of the HEDIS certification and recertification processes—and Cotiviti's approach to minimizing recertifications.

Watch the video

HEDIS® is a registered trademark of the National Committee for Quality Assurance.


Jamison Gillitzer
Jamison is a senior product director supporting Cotiviti’s Quality and Performance solution suite. His primary responsibilities are the successful delivery of our quality solutions to ensure they meet clients' needs in support of HEDIS, P4P, and other quality reporting initiatives. He also works to develop and enhance our capabilities to support evolving quality requirements. Jamison has a bachelor's degree in entrepreneurial management from the University of Minnesota and is PMC-III certified.

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