2021 HEDIS® measures

Updated January 2021

The tables below explain the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures for two types of care: preventive health care (children and adolescents, women and adolescent girls, adults, and seniors) and condition-specific care.

The Centers for Medicare and Medicaid Services (CMS) created the Medicare Advantage Five-Star Quality Rating System to measure the quality of, and reflect the experiences of beneficiaries enrolled in health plans. Measures with a five-star symbol (*****) are designated 2021 Medicare Five-Star Measures.

New for HEDIS MY 2020

Measure

Care, screening or test

Well-child visits in the first 30 months of life

 

Six or more well-child visits (Well-Care Value Set) on different dates of service on or before the 15-month birthday.

Two or more well-child visits on different dates of service between the child’s 15-month birthday plus 1 day and the 30-month birthday.

The well-child visit must occur with a PCP, but the PCP does not have to be the practitionerassigned to the child.

Cardiac rehabilitation



18 years and older who attended cardiac rehabilitation following a qualifying cardiac event, including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, heart and heart/lung transplantation or heart valve repair/replacement.

Kidney health for patients with diabetes

The percentage of members 18–85 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).

Osteoporosis screening in older women Women 65–75 years of age who received osteoporosis screening

Children and adolescents

Measure

Care, screening or test

Weight assessment and counseling for nutrition and physical activity for children and adolescents.
Ages 3-17 years

Patients 3-17 who had evidence of body mass index (BMI) percentile including height and weight, counseling or referral for nutrition or indication nutrition was addressed. Counseling or referral for physical activity or indication physical activity was addressed during an outpatient visit either by a claim or as a medical record entry.

Child and adolescent well-care visits

Ages 3-21 years

Annual well-care visit with a PCP or OB/GYN.

Childhood immunization

Series must be completed by the second birthday

  • 4 DTaP (none prior to 42 days of age)
  • 3 IPV (none prior to 42 days of age)
  • 1 MMR or documented history of illness or a seropositive test occurring prior to second birthday
  • 3 HiB (none prior to 42 days of age)
  • 3 HEP B or documented history of illness or a seropositive test occurring prior to second birthday
  • 1 HEP A or documented history of illness or a seropositive test occurring prior to second birthday
  • 1 VZV, or documented history of illness or a seropositive test occurring prior to second birthday
  • 2-3 rotavirus (none prior to 42 days of age)
  • 2 influenza (Added live attenuated influenza vaccine (LAIV)

Immunizations for adolescents
13 year-olds

  • 1 meningococcal vaccine on or between the member’s 11th or 13th birthday ("meningococcal conjugate vaccine” or “meningococcal polysaccharide vaccine” meet criteria)
  • 1 Tdap or 1 Td on or between the member’s 10th or 13th birthday
  • 3 doses of HPV vaccine with different dates of service, on or between the ninth and 13th birthday.

OR

  • 2 doses of HPV with different dates of service and at least 146 days between doses on or between the ninth and 13th birthdays.

Exclusions: anaphylactic reaction to the vaccine or its components

Lead screening in children (Medicaid only)

Children aged 2

Children who received at least one capillary or venous lead screening test on or before their second birthday.

Treatment of children with upper respiratory infections

Ages 3 months-
18 years

Children three months to 18 years who were given a diagnosis of upper respiratory infection (URI) and were NOT dispensed an antibiotic prescription within three days of the URI diagnosis.
Exclusions:

  • Encounters with > 1 diagnosis
  • Children with a history of antibiotic Rx within 30 days of encounter

Follow-up care for children prescribed ADHD medication

Ages 6-12 years

Children who received an initial prescription for ADHD medication and:

  • Received at least one follow-up visit with a prescriber within 30 days of initiation of medication
  • Remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two more follow-up visits between four weeks and nine months

Women and adolescent girls

Measure

Care, screening or test

Chlamydia screening
Age 16-24 and sexually active

Women identified as presumed sexually active by pharmacy Rx data or claims data indicating potential sexual activity

  • Screening test for chlamydia yearly

Exclusions:

  • Women who had a pregnancy test followed within seven days by either a prescription for Accutane (isotretinoin) or an X-ray.

Non-recommended cervical cancer screening in adolescent females

Adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer (lower score is better).

*****Breast cancer screening

Age 50-74

Mammogram in the measurement year or one year prior.

Exclusions:

  • Women who have had bilateral mastectomy or two unilateral mastectomies
  • Women 81 and older with frailty or advanced illness

Prenatal and
Postpartum care

Pregnant women

Prenatal visit during the required timeframe these timeframes are based on member enrollment.

Postpartum visit to an OB/GYN or other prenatal care practitioner or PCP between 7 and 84 days after delivery.

Cervical cancer screening

Ages 21-64

The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:

Women 21–64 years of age who had cervical cytology performed within the last 3 years.

Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.

Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last five years.

Exclusions:
Women who have had a complete hysterectomy with no residual cervix.

Prenatal (PND) and postpartum (PDS) depression screening and follow-Up

The PND measure assesses the proportion of deliveries in which members were screened for clinical depression while pregnant and if screened positive, received follow-up care. Two rates are reported.

  • Depression Screening
    The proportion of deliveries in which members were screened for clinical depression using a standardized instrument during pregnancy.
  • Follow-Up on Positive Screen
    The proportion of deliveries in which members received follow-up care within 30 days of screening positive for depression.

The PDS measure assesses the proportion of deliveries in which members were screened for clinical depression during the postpartum period, and if screened positive, received follow-up care. Two rates are reported.

  • Depression Screening
    The proportion of deliveries in which members were screened for clinical depression using a standardized instrument within 12 weeks (84 days) after delivery.
  • Follow-Up on Positive Screen
    The proportion of deliveries in which members received follow-up care within 30 days of screening positive for depression.

Adults

Measure

Care, screening or test

Adults’ access to preventive/ambulatory health services
Ages 20 and older

Patients 20 years and older who had an ambulatory or preventive care visit.

*****Colorectal cancer screening

Ages 50-75

One or more of the following screenings:

  • Fecal occult blood test annually
  • FIT-DNA test every three years
  • Flexible sigmoidoscopy every five years
  • CT colonography every five years
  • Colonoscopy every 10 years

Exclusions:

  • Colorectal cancer
  • Total colectomy
  • Members 81 and older with frailty or advanced illness or dementia
  • Hospice and palliative care

Non-recommended PSA-based screening in older men (PSA)

Men 70 years and older who were screened for prostate cancer using prostate-specific antigen (PSA)-based testing (lower score is better).

*****Plan all-cause readmissions

Percentage of acute inpatient stays followed by an acute readmission for any cause within 30 days for 18 years and older.

*****Osteoporosis management in women who had a fracture

Age 67 - 85

Women who received the following within six months of suffering a fracture:

  • Bone mineral density (BMD) test
  • Prescription for a drug to treat or prevent osteoporosis in the six months after the fracture

Exclusions:

  • Women who received a BMD screening in the two years prior to the fracture.
  • Women who received a prescription for a drug to treat or prevent osteoporosis 12 months prior to the fracture
  • Fractures of the finger, toe, face and skull are not included in this measure.
  • Women 81 and older with frailty or advanced illness
Transitions of care

18 years of age or older
The percentage of discharges for members who had each of the following during the measurement year. Four rates are reported:

  • Notification of inpatient admission
    Documentation of receipt of notification of inpatient admission on the day of admission or the following day
  • Receipt of discharge information
    Documentation of receipt of discharge information on the day of discharge or the following day
  • Patient engagement after inpatient discharge
    Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days of discharge.
  • Medication reconciliation post-discharge
    Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).

NaviCare

Measure

Care, screening or test

*****Care for older adults
Age 65 years and older

Adults aged 65 and older who had each of the following during the measurement year:

  • Advance care planning
  • Medication review
  • Functional status assessment
  • Pain assessment

 

Condition-specific care

Alcohol and other drug dependence

Measure

Care, screening or test

Initiation and engagement of alcohol and other drug (AOD) dependence treatment

Ages 13 and older:
13-17 years
18+ years
Total

Patients diagnosed with alcohol and other drug dependence who:

  • Initiate treatment within 14 days of diagnosis
  • Receive two additional AOD services within 30 days of initiation

Follow-up after emergency department visit for alcohol and other drug dependence

13 years of age and older with a principal diagnosis of alcohol or other drug dependence

  • The percentage of ED visits for which the member received follow-up within 30 days of the ED visit.
  • The percentage of ED visits for which the member received follow-up within seven days of the ED visit.

Risk of continued opioid use

18 years of age and older

The percentage of members 18 years and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:

  • The percentage of members whose new episode of opioid use lasts at least 15 days in a 30-day period.
  • The percentage of members whose new episode of opioid use lasts at least 31 days in a 62 day period.

Pharmacotherapy for opioid use disorder

The percentage of new opioid use disorder pharmacotherapy events with OUD pharmacotherapy for 180 or more days among members age 16 and older with a diagnosis of OUD.

Follow-up after high-intensity care for substance use disorder

The percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:

  • The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
  • The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.

Asthma

Measure

Care, screening or test

Asthma medication ratio

Ages 5-85 years
Age stratifications:
5-11 years
12-18 years
19-50 years
51-64 years
65-85 years
Total rate

The percentage of members 5–85 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

Exclusions: Emphysema, COPD, cystic fibrosis, acute respiratory failure or no dispensed medications.

Cardiac

Measure

Care, screening or test

Persistence of beta-blocker treatment after heart attack

Age 18 and older

Patients who were hospitalized and discharged alive after an acute MI who:

  • Received treatment with beta-blockers for six months after discharge

Exclusions:

  • Patients identified as having a contraindication to beta-blocker therapy
  • Patients with a history of adverse reaction to beta-blocker therapy

Controlling high blood pressure

Age 18-85

Patients 18-85 with a diagnosis of hypertension whose most recent blood pressure reading was controlled (<140/90 mm Hg) in the measurement year (taken by any digital device).

Exclusions:

  • Patients with end stage renal disease (ESRD) or kidney transplant
  • Pregnant during the measurement year
  • Admission to a non-acute inpatient setting during the measurement year
  • Members 81 and older with frailty or advanced illness
  • Palliative care

Chronic obstructive pulmonary disease (COPD)

Measure

Care, screening or test

Use of spirometry testing in the assessment and diagnosis of COPD

Ages 40 and older

Adults with a new (within the measurement year) diagnosis or newly active COPD who received spirometry testing to confirm the diagnosis.

  • Spirometry testing must occur 730 days prior to or 180 days after the diagnosing event.

Pharmacotherapy management of COPD exacerbation
Adults 40 and older

Adults aged 40 or older who had an acute inpatient discharge or an ED encounter with a principal diagnosis of COPD who were dispensed both:

  • A systemic corticosteroid within 14 days of discharge
  • Bronchodilator within 30 days of discharge

NOTE: the eligible population for this measure is based on the discharges and visits, not the patient. It is possible for the denominator for this measure to include multiple events for the same patient.

Depression

Measure

Care, screening or test

Antidepressant medication management

Ages 18 years and older

Adults newly diagnosed with depression and treated with an antidepressant who received the following:

  • Effective acute phase: filled sufficient number of Rx to allow for 84 days of continuous therapy.
  • Effective continuation phase: filled sufficient number of Rx to allow for 180 days of continuous therapy.

To qualify as a new diagnosis, two criteria must be met:

  • A 120-day (four-month) negative diagnosis history on or before the start date
  • A 90-day (three-month) negative medication history on or before the start date

Diabetes

Measure

Care, screening or test

*****Comprehensive diabetes care

Age 18-75
*****

Yearly screening of the following:

  • HbA1c testing
  • HbA1c result > 9.0 = poor control
  • HbA1c result < 8.0 = good control
  • Retinal eye exam
  • Monitoring for nephropathy
  • Blood pressure reading < 140/90 (taken by any digital device)

Exclusions

  • Members 81 and older with frailty or advanced illness
  • Palliative care
  • Polycystic ovarian syndrome (PCOS)

Mental illness

Measure

Care, screening or test

Follow-up after hospitalization for mental illness

Age 6 and over

Patients discharged from an inpatient mental health admission and received:

  • One follow-up encounter with a mental health provider within seven days after discharge.
  • One follow-up encounter with a mental health provider within 30 days after discharge.

Rheumatoid arthritis

Measure

Care, screening or test

*****Anti-rheumatic drug therapy for rheumatoid arthritis

Patients 18 years and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).

Exclusions

  • Members 81 and older with frailty or advanced illness

Tobacco users

Measure

Care, screening or test

Medical assistance with smoking cessation

Tobacco users age 18 and older

Current smokers who were seen by a practitioner during the measurement year and:

  • Received advice to quit
  • Cessation medications were recommended and discussed
  • Cessation methods were recommended or discussed

Information is received via CAHPS®** survey methodology.

Other

Measure

Care, screening or test

Appropriate testing for pharyngitis

3 years of age and older

Children who had an outpatient visit or ED encounter with only a diagnosis of pharyngitis who were dispensed an antibiotic and also received a Group A streptococcus test three days before or three days after the prescription.

Exclusions:

  • Encounters with > 1 diagnosis

Children with a history of antibiotic Rx within 30 days of encounter

Avoidance of antibiotic treatment for acute bronchitis

Ages 3 months of age and older

Members diagnosed with acute bronchitis who did not receive an antibiotic Rx on or within seven days of diagnosis.

* HEDIS® is a registered trademark of NCQA.

** CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality.

***** Indicates Medicare 5-Star measures