Understanding CMS’s Proposed Changes for Play Year 2026: Key Insights from the Draft 2025 Call Letter

In the newly released Draft 2025 Call Letter for the Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey, CMS has outlined proposed changes for Play Year 2026 and beyond. Here’s what you need to know.

What’s Changing in the 2025 QRS Draft?

A quick look at CMS’s key proposed updates for Play Year 2026:

Key Proposed Changes

1. Measure Removals

• CMS proposes removing the International Normalized Ratio Monitoring for Individuals on Warfarin (INR) and Annual Monitoring for Persons on Long-Term Opioid Therapy (AMO) measures.​
• The Social Need Screening and Intervention (SNS-E) measure is also proposed for removal.

Impacts:

• INR: Current clinical guidelines strongly recommend the use of Direct-Acting-Anticoagulants (DOACs) over Warfarin because DOACs demonstrate comparable efficacy for several indications and do not need frequent international normalized ratio monitoring and dietary restrictions. Since the emergence of DOACs in the last two decades, the utilization of Warfarin has steadily decreased across demographics (Navar et. al., JAHA 2022).
• However, studies and previous years’ QRS results indicate that despite the decreasing trend in Warfarin utilization, many providers continue to prescribe the drug.  Removal of the INR measure, therefore, may impact patient safety for individuals that are still on said drug regimens. QRS results for 2024 indicate that 20,000 beneficiaries across the country received Warfarin therapy and 48% of plans qualified for scoring for this measure. Given these numbers, we agree with the proposal to remove the measure from a quality benchmarking standpoint. However, we urge health plans with members on Warfarin therapy to rollout provider steering strategies to facilitate adoption of DOACs in accordance with clinical best practices.
• AMO: According to the 2024 QRS data, 114K beneficiaries received long-term opioid therapy across the country and 76% of plans were scored for this measure. Recent studies have indicated a decrease in opioid prescription for treatment of chronic non-cancer pain, down to 30% in 2019 (Bandara et. al., Plos One, 2019). However, given the significant risks associated with long-term opioid use and that the majority of plans continue to score for this measure, we recommend delaying the exclusion of this measure. This would allow time for more current assessments of clinical trends in long-term opioid utilization and further decrease in utilization among beneficiaries.
• SNS-E: Health plans may inadvertently overlook critical non-medical factors that significantly impact patient health, such as housing instability, food insecurity and access to transportation. Without this measure, health plans may also have fewer incentives to develop and implement targeted programs that address these social determinants of health. This could potentially exacerbate existing health disparities and widen inequities in care, particularly among vulnerable populations who are already at a higher risk for poor health outcomes.

2. Measure Addition:

• A new "Enrollee Experience with Cost" measure is proposed to assess enrollees' perspectives on healthcare costs.​

Impact:

• The introduction of the "Enrollee Experience with Cost" measure could drive health plans to focus more on affordability, transparency and consumer satisfaction. It will likely influence plan ratings, consumer choices and health equity initiatives while pushing insurers to improve cost control mechanisms. The measure has the potential to create a more transparent, consumer-centric healthcare environment where cost is a key factor in both plan selection and patient satisfaction.

3. Measure Transition:

• The existing Controlling High Blood Pressure (CBP) measure may transition to the Blood Pressure Control for Patients with Hypertension (BPC-E) measure.​

Impact:

• This change may enhance health equity by targeting vulnerable populations, promoting a more patient-centered approach and encourage long-term, comprehensive care. Health plans and providers will need to adjust their practices and reporting systems to align with this more focused measure, which could lead to better quality ratings in the QRS and improved care for high-risk individuals

4. Measure Refinements:

• Proposed refinements include updates to the Breast Cancer Screening (BCS-E) and Adult Immunization Status (AIS-E) measures.​

Impact

• These updates may enhance preventative care efforts by expanding the eligible population and addressing age-related disparities. Lowering the BCS-E screening age to 40 encourages earlier detection for younger women, who historically have lower screening rates. Health plans and providers will need to implement age-targeted outreach, adjust clinical workflows and enhance provider communications to support this change. Stratified reporting by age bands may also help to identify gaps in care and inform quality improvement strategies.
• The additional indicator for Hepatitis B vaccine in adults 19-59 supports increased vaccine uptake and aligns with NCQA. However, capturing data from sources such as pharmacies and public clinics may present interoperability challenges. Health plans may need to strengthen data-sharing capabilities and implement targeted member and provider engagement strategies to raise awareness and improve vaccination rates.

Electronic Clinical Data System (ECDS) Reporting Expansion:

• CMS plans to transition certain measures, such as Cervical Cancer Screening (CCS-E), Immunizations for Adolescents (IMA-E) and Childhood Immunization Status (CIS-E), to ECDS-only reporting.​

Impact:

• The shift to ECDS-only reporting for Cervical Cancer Screening, Immunizations for Adolescents, Childhood Immunization Status and Blood Pressure Control could accelerate the adoption of more integrated, data-driven care. Health plans may be pushed to strengthen partnerships with providers and invest in better clinical data exchange to ensure accurate reporting. This move could improve care visibility and lead to more timely interventions, but it may also challenge plans with limited access to EHR or HIE data. Ultimately, this transition supports a more holistic and proactive approach to quality measurement, but readiness and infrastructure will play a key role in performance success.

QHP Enrollee Survey Sample Frame Revisions:

• Revisions are proposed for the QHP Enrollee Survey sample frame variables to enhance data accuracy.​

Impact:

• The revisions to the QHP Enrollee Survey may improve the comparability of QHPs, identify areas for improvement and promote better health equity by ensuring that underserved populations are adequately represented. Adjustments to data collection and reporting processes may be necessary, while consumers could benefit from more trustworthy quality ratings to guide their healthcare decisions.

How ProspHire Can Help

Our team at ProspHire is closely tracking these developments to help you stay compliant, competitive and ahead of industry shifts.

Want to talk through how these changes may impact your quality strategy or operational planning? We’re here to help.