The Measure Ahead

Standing Still Now Costs You a Rating Band

An unchanged rate can lose ground when the benchmark around it rises. A Medicaid plan that sat right at last year's measure-level 4-star threshold on blood pressure control, glycemic control or kidney health evaluation, and held that rate flat, would have landed in the middle third of the national distribution in MY2025. The rate didn't fall. The bar rose around it.

NCQA's 2026 Health Plan Ratings tell the headline version. Average benchmark performance rose across commercial, Medicaid and Medicare Advantage. Medicaid improved on 89% of measures, the broadest gain of any product line. And the gap between high and low performers narrowed in every product line.

NCQA's Medicaid ratings show the shift at the top. Four Medicaid plans earned five stars on the 2026 report card; in 2025, as in 2024, none did. The share of rated plans at four stars or higher rose from 29% to 35%.

The four-star group grew from 48 to 59 plans while the 3.5-star group shrank from 93 to 85. At the other end, 57 plans rated 3.0 stars or lower in both years. These are year-over-year totals; they do not show which individual plans moved. About two in three rated Medicaid plans still sit at 3.5 stars or lower.

The national MY2025 Medicaid benchmarks show where the movement happened. Percentile thresholds moved up on most measures that depend on captured clinical data: Controlling High Blood Pressure, Blood Pressure Control for Patients With Diabetes, glycemic status, Kidney Health Evaluation, colorectal screening, prenatal and postpartum care, weight assessment and counseling, well-child visits and the asthma medication ratio. Some of the largest moves were on kidney health evaluation and colorectal screening.

That pattern is not unique to Medicaid. An industry analysis of CMS's draft 2027 Star Ratings cut points found they tightened sharply on the same two measures: kidney health evaluation by 7 to 10 points and colorectal screening by 4 to 11 points, depending on star level. Across product lines, the bar rose most on measures that depend on clinical data reaching the plan.

Three details worth a closer look

1. Where the hybrid method went away, results came in lower. NCQA removed the hybrid method from four measures in MY2025: eye exams became administrative-only, while cervical screening, childhood immunizations and adolescent immunizations became ECDS-only. National medians for eye exams, cervical screening and childhood immunizations came in below the prior year's hybrid-era results, alongside other specification changes. Adolescent immunizations held roughly level. NCQA notes that the effect of removing the hybrid method varies by measure. Treat it as the preview for blood pressure, glycemic control, prenatal care and WCC, unless electronic capture is built first.
2. Eye exams now have a lower bar. EED benchmarks declined, and NCQA flagged diabetic eye exam performance as an area needing attention. With hybrid chart review retired, every exam has to arrive through claims or supplemental data, including record evidence captured as supplemental data. Plans that build that feed are climbing against a lower bar.
3. The behavioral health jump is not a trend. NCQA reported follow-up after psychiatric hospitalization (FUH) up 9.0 points in Medicaid. But MY2025 re-specified the measure: anxiety and phobia diagnoses joined the denominator, and visits with any mental health diagnosis, peer support and residential treatment now count as follow-up. NCQA's own trending memo predicted a break in trending for FUH. The reported increase can't, by itself, separate changes in access from changes in the specification.

Season Zero: The 2027 Hybrid Season Starts Now

The plans that close MY2026 strongest will not win it in February, when the 2027 hybrid season opens. They will win it in the next 90 days, while the measurement year is still open. Some gaps can still be closed with care delivered before December 31. Others need better evidence of care already delivered. Sort which is which before you assign the year-end work.

The fourth-quarter push was built for a world where the bar held still. It doesn't anymore. When thresholds keep rising, a once-a-year sprint can only find what already happened. Prospective data collection, running all year, is how plans keep pace.

First, know which method each measure uses. Here is where selected Medicaid measures stand for MY2026:

State contracts and EQRO requirements can add to this list. Confirm yours before you finalize the sample plan.

Note: Care for Older Adults (COA) and Transitions of Care (TRC) are Medicare measures; COA is reported by Special Needs Plans, including D-SNPs. We will review both in the Stars issue.

What to do between now and December 31

1. Work the open hybrid gaps while care can still close them. Blood pressure and glycemic control both count the most recent reading in the year. A controlled reading at a fourth-quarter visit can close a gap that no February chart pull ever could. Pair outreach with prospective chart collection so the reading is captured as soon as it exists.
2. Lock retrieval logistics before January. Build the provider and site roster now, with the retrieval route for each: remote EMR access, vendor, fax or onsite. Remote access agreements take weeks to negotiate, not days.
3. Calibrate abstraction early. Run inter-rater reliability and refresh overread rules before the first chart arrives, not after the first error. Medical record review validation is won in preparation, long before the auditor selects a chart.
4. Get every supplemental source into the Roadmap now. Nonstandard sources that are documented late risk being disallowed when the audit cutoffs hit. Standard feeds for labs and CPT II blood pressure codes reduce the number of charts you need at all.
5. Watch the sample timing. NCQA moved RAND numbers out of Volume 2 beginning with MY2025 and distributes them on its own timeline. Know when yours arrive so systematic samples don't slip.

One Chart, Many Measures

Every chart you retrieve for a hybrid sample is also a record of that member's other care. One retrieval can serve every measure the member is eligible for, not only the measure that put them in the sample.

Build the member-by-measure eligibility map first. Then the overlap is larger than most plans use:

• A member with diabetes sampled for glycemic or blood pressure control is often also eligible for the eye exam and kidney health measures, and may be due for breast, cervical or colorectal screening. Confirm eligibility, service dates and data requirements for each measure separately.
• A member sampled for prenatal and postpartum care may have prenatal immunizations and depression screening documented in the same record.
• A 13-year-old sampled for WCC may carry the immunization history the adolescent immunization measure needs in the same chart.

Evidence found outside the hybrid measure has to enter another way. For administrative measures, it comes in as nonstandard supplemental data. For ECDS measures, NCQA allows data abstracted from medical records only if it is captured and stored in structured formats with standard layouts, meets the ECDS data source requirements, and is available to the member's care team on request. Either way, these sources are audited under the supplemental data validation requirements, so your abstraction tool has to produce structured, documented output. Widening the evidence you collect does not change the hybrid sample or relax any other measure's criteria.

Keep prospective collection running through hybrid season

Many plans pause prospective chart collection when the hybrid sample lands. That is backwards. Hybrid season is the one time of year your retrieval operation is already in every provider office. Add the non-hybrid gaps for the same site to the same request, and keep collecting MY2026 evidence right up to your auditor's supplemental data cutoffs. Evidence of 2026 services counts toward MY2026; prospective collection for MY2027 is a separate workstream with its own service dates.

The trade-offs, stated plainly

• Cost per chart goes up. Abstractors read more of each record. Prioritize by clinical importance, eligible volume, evidence yield and how close each measure sits to a rating threshold.
• Audit exposure goes up. Every nonstandard source faces primary source verification. Document and quality-check it as carefully as the hybrid abstraction, or it can cost you the whole source.
• Hybrid turnaround must not slip. Run the extra abstraction as a second pass or a separate queue, so the sample stays on schedule.
• Provider patience is finite. Bundle requests by site. Three separate asks to one office is how charts stop arriving.

This is the operating model DavisJones runs: an average sub-48-hour retrieval-to-overread turnaround, and a 100% MRRV pass rate across more than 100 hybrid projects. Extra closures only count if the season still closes clean.

A good season should also leave more than completed charts. It should show which sources kept supplying missing evidence, where validation failed, and which data connections to fix before the next cycle, so next year needs fewer charts, not another round of the same chase.

CMS Briefing: What Changed Since Our Last Issue

Marketplace and QRS: Rating a Membership That Just Changed Shape

Marketplace plans will be rated next year on a population that looks different from the one they planned for. February effectuated enrollment fell 13% from 2025 to 2026 after the enhanced premium tax credits expired. KFF projects the full-year average could fall 21.5%, to about 17.5 million, as members who stop paying higher premiums lose coverage mid-year. Those who stayed moved toward bronze plans, and the average deductible rose by about $1,000. These are national figures; check your own membership before drawing conclusions.

That can show up in Quality Rating System results in four ways:

1. Eligibility. Among other criteria, a reporting unit must have more than 500 enrollees as of July 1 of the prior year and as of January 1 of the ratings year to be required to report. Units that shrank below that line may drop out of the ratings consumers compare.
2. Denominators. QRS clinical measures and the enrollee survey both require continuous enrollment. Coverage interruptions can remove members from measure denominators or survey frames when they exceed the applicable allowable gap or cause a member to miss a required enrollment date. Smaller denominators mean bigger swings from small changes.
3. Mix. Young adults ages 18 to 34 accounted for 46% of the drop in sign-ups. A plan's rates can move this year with no change in the care it delivers, simply because a different group of people is being measured. Higher deductibles can also delay the follow-up visits and tests some measures depend on.
4. Survey samples. Smaller sample frames can mean fewer completed surveys and less stable scores.

What Marketplace quality teams should do now

• Re-forecast on the members you have. Re-run internal QRS projections on current continuous-enrollment populations, not 2025 membership.
• Separate mix from performance. Segment rates by enrollment cohort and metal level, so leadership can see what changed because of who left versus what changed in care.
• Protect the survey. Oversample where the frame allows. Before any member communication about the survey, have your survey vendor confirm it fits CMS's rules.
• Watch the cost questions. Enrollee experience with cost is the domain most exposed to the deductible shift. Pair those results with access and utilization data before drawing conclusions.

We will cover the QRS results, and what changes in scoring, once CMS releases the ratings.

A Smaller HEDIS®, Written for Machines

NCQA has finalized the retirement of 10 HEDIS measures for MY2027, confirmed in an update posted September 30. They come out of Volume 2 with the March 2027 Technical Update. Several are Medicaid staples: Oral Evaluation, Dental Services; Topical Fluoride for Children; Use of Opioids at High Dosage; Risk of Continued Opioid Use; Diagnosed Mental Health Disorders; Diagnosed Substance Use Disorders; and the two schizophrenia monitoring measures. Check your state contracts before you drop anything: some states require measures NCQA no longer carries.

The additions point the same direction. All six new MY2027 measures use ECDS reporting, including follow-up colonoscopy after a positive non-invasive colorectal screening test, prenatal syphilis screening and continuous glucose monitor use. Glycemic Status Assessment gains an optional ECDS version. New measures now assume electronic clinical data from day one.

The hybrid timeline holds. NCQA has kept the MY2029 end date for the hybrid method while adjusting individual measure pathways. WCC retires in MY2029 while NCQA develops a replacement. For prenatal and postpartum care, NCQA is developing a new ECDS, risk-based replacement targeted for MY2028, with the hybrid version retiring at the same time. Replacements still in development are not final specifications.

Two MY2028 changes deserve a place on your roadmap now:

• Specifications get more precise about data sources. NCQA released a memo previewing MY2028 enhancements that clarify data source expectations, so narrative specifications translate consistently into computable logic. The questions your auditor asks about where data came from are moving into the measure itself.
• Denied claims start to count. NCQA will remove the denied-claims exclusion from a set of overuse, utilization and risk-adjusted utilization measures, including the antibiotic and imaging overuse measures, Plan All-Cause Readmissions and Emergency Department Utilization. Confirm the final list against the MY2028 specifications. Some rates will shift from the counting change alone, so build that into trend explanations now.

See You in Atlanta

DavisJones will be at the NCQA Health Innovation Summit, October 4–7 at the Georgia World Congress Center. This year's theme is Quality's Next Chapter, and advancing digital quality sits at the center of it. If you are there, find us. We would love to compare notes on the new benchmarks and what your team is planning for MY2026.

What needs to be ready before January?

Bring one priority measure or reporting challenge to a no-cost, 30-minute readiness conversation with DavisJones. We will talk through the reporting framework that applies, your data and retrieval workflow, and the decisions your team needs to make next. No member-level data needed.

1. NCQA Blog, NCQA Releases 2026 Health Plan Ratings (September 16, 2026)
2. NCQA, Health Plan Report Card, Medicaid (2026 ratings) and 2025 Health Plan Ratings final summary results (Medicaid, September 1, 2025)
3. Becker's Payer Issues, The best-rated Medicaid plans of 2025: NCQA
4. NCQA, Health Plan Ratings vs. Medicare Part C and Part D Stars Methodology FAQs (2026)
5. NCQA, HEDIS® MY 2025 Measure Trending Determinations (September 2025)
6. NCQA, ECDS Frequently Asked Questions
7. NCQA, HEDIS® Electronic Clinical Data Systems (ECDS) Reporting
8. NCQA Blog, HEDIS® MY 2027: What's New, What's Changed, What's Retired (August 3, 2026; updated September 30, 2026)
9. RISE Health, HEDIS® MY 2027 specs are here: a rapid readout
10. Medical Daily, Half of Medicare Advantage Quality Thresholds Got Harder for 2027 (September 14, 2026), reporting an industry analysis of CMS draft cut points
11. RISE Health, How the Clover ruling prompted more plans to speak up on Star Ratings and CMS appealed the Clover ruling
12. Healthcare Finance News, CMS challenges court-ordered boost to Clover's star ratings
13. NCQA, Standardized Data Collection for MAC QRS Reporting; Myers and Stauffer, Medicaid and CHIP Quality Rating System
14. McDermott+, CMS drops interim final rule implementing Medicaid work requirements
15. CMS, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet
16. KFF, ACA Marketplace Enrollment Is Down By 3 Million and The Average Marketplace Deductible Grew by About $1,000 Per Person in 2026
17. AJMC, ACA Marketplace Enrollment and Affordability Take Historic Hit
18. CMS, 2026 QRS and QHP Enrollee Survey Operational Instructions
19. NCQA Blog, Counting Down to the Health Innovation Summit; NAHQ, Healthcare Quality Week