The Healthcare Effectiveness Data and Information Set (HEDIS) is a nationally recognized framework of measures that evaluates how effectively health plans deliver care, manage chronic conditions, ensure access to services and utilization, and support patient experiences. Maintained by the independent, nonprofit National Committee for Quality Assurance (NCQA), these measures allow comparisons across plans, drive accountability and improvement, and inform reporting.
Of the 90 HEDIS measures, five directly apply to the substance use disorder (SUD) domain, an area of healthcare that has been identified as critical to value-based care. Untreated SUDs drive higher usage of healthcare services—emergency room visits, inpatient stays, infections, and comorbidities – leading to higher costs.
Health plans that meet HEDIS requirements are recognized for providing higher-quality care, increased patient satisfaction and retention, and can differentiate themselves in the broader marketplace. Meeting HEDIS measures has numerous advantages, but it can be challenging for health plans to manage the volume of data, coordinate care, and maintain patient engagement at the necessary levels without support.
Digital tools, such as CHESS Health’s solutions for SUD risk assessment, closed-loop referrals, care facilitation, communication between care providers and patients, and recovery support, can provide a stabilizing bridge for health plans seeking to meet HEDIS measures for SUD care.
Why HEDIS Performance Matters: The Business Case
Health plans that meet HEDIS requirements are recognized for providing higher-quality care and increased patient satisfaction, but the business impact extends far beyond reputation. Strong HEDIS performance directly affects a health plan’s bottom line and competitive position in three critical ways:
Revenue & Market Access
Star Ratings drive Medicare Advantage revenue—HEDIS measures feed into CMS Star Ratings, which directly impact bonus payments. A plan moving from 3.5 to 4 stars can receive millions in additional federal funding. Beyond Medicare, large employers and benefit consultants use HEDIS scores as key selection criteria when deciding which plans to offer employees, making performance a gatekeeper to lucrative employer groups. Additionally, many state Medicaid programs tie reimbursement rates or contract renewal to HEDIS performance, meaning subpar scores can cost plans both revenue and market access.
Member Retention & Growth
Plans with better HEDIS scores often see higher member satisfaction and retention, reducing costly member acquisition expenses. Strong public reporting of HEDIS results serves as a competitive differentiator in the marketplace, helping plans attract new members while keeping existing ones engaged and loyal.
Cost Management
Many HEDIS measures focus on preventive care and chronic disease management, including SUD. While the Plan All-Cause Readmissions (PCR) measure tracks 30-day hospital readmissions broadly, the SUD-specific challenge centers on recurring returns to higher-cost levels of care, including avoidable ED visits, repeated detox admissions, and multiple residential treatment episodes. Untreated or poorly managed substance use disorders drive these costly cycles of crisis intervention rather than sustained recovery. Better SUD management and long-term recovery support significantly reduce these recurring high-cost interventions while also decreasing expenses associated with physical health complications and co-occurring mental health conditions, creating a sustainable cost structure that benefits both the plan and its members.
Meeting HEDIS measures delivers these advantages, but it can be challenging for health plans to manage the volume of data, coordinate care, and maintain patient engagement at the necessary levels without support. Digital tools, such as CHESS Health’s solutions for SUD risk assessment, closed-loop referrals, care facilitation, communication between care providers and patients, and recovery support, can provide a stabilizing bridge for health plans seeking to meet HEDIS measures for SUD care.
Key HEDIS Measures for Substance Use Disorder
For HEDIS measures directly related to SUD care, CHESS Health’s digital tools are uniquely designed to help health plans meet the requirements and document their efforts and results with robust data.
Initiation and Engagement of Substance Use Disorder Treatment (IET)
What is required: This measure assesses how quickly and consistently people start and continue treatment after diagnosis of SUD. With checkpoints at 14- and 34-days post-diagnosis, this measure aims to ensure that people don’t fall through the cracks after diagnosis and remain engaged in care, increasing their chances of achieving recovery.
How CHESS Health can help: The automated screening capabilities provides enhanced prevention with smart interventions and ability to self-refer within a closed-loop referral platform to streamline the referral process and enhance communication between providers. The suite of recovery support tools, including an innovative peer-powered recovery support app keeps people engaged in their recovery and treatment from the first day, offering 24/7 support and crisis response. CHESS Health tools assist health plans in maintaining communication with patients as they navigate sometimes lengthy waitlists for care.
Follow-Up After Emergency Department Visit for Substance Use (FUA)
What is required: The FUA measure checks whether people get timely follow-up care after going to the emergency room for an issue related to SUD, such as overdose, intoxication, or another SUD crisis. The measure looks for follow-up within 7 days and again within 30 days to reduce the risk of another crisis, connect them to ongoing care and support, and improve the care transition from the ER.
How CHESS Health can help: Here again, our care coordination capabilities smooths the path by providing closed-loop, trackable referrals to ensure individuals are connected to essential services and treatment.
Diagnosed Substance Use Disorders (DSU)
What is required: The DSU measure tracks how many people in a health plan have been diagnosed with SUD during the year, aiming to report how common SUD diagnoses are in the community. This measure is purely about numbers; it is not concerned with treatment or follow-up care. It provides a snapshot of SUD prevalence, not of treatment quality.
How CHESS Health can help: The automated screening tools provide individuals an opportunity to complete screenings privately or during visits with a healthcare provider, identifying people at risk and capturing data. Many CHESS Health clients who use this tool leverage the turn-key marketing and promotional toolkit that is part of the solution to widely share weblinks and QR codes so individuals can take the assessments on their own, removing barriers to screening.
Follow-Up After High-Intensity Care for SUD (FUI)
What is required: FUI measures whether people get timely follow-up care after leaving high-intensity treatment (inpatient care, residential treatment, or intensive outpatient programs) for SUD. This measure is designed to ensure that people stay connected to care when they are most vulnerable. It tracks follow-up visits within 7 days and again at 30 days. Follow-up visits can be with therapists or primary care providers, peer-support services, medication services, or other outpatient SUD services.
How CHESS Health can help: The Connections 24/7 peer-backed recovery support app, provides 24/7 support to individuals in recovery. This essential tool fills the critical gaps between treatments and appointments, when people in recovery from SUD find themselves most at risk.
Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
What is required: This measure checks whether individuals 18 and older are routinely screened for unhealthy alcohol use, and whether people who screen positive receive help. Screening can occur at any level of care and assesses how often someone drinks, how much, and whether drinking has caused problems. If the screening is positive, providers are to offer follow-up care, such as brief counseling, education about reducing drinking, referral to treatment, or other options.
How CHESS Health can help: Automated, customizable screening tools include the clinical practice of SBIRT (Screening, Brief Intervention, Referral to Treatment) by integrating an evidence-based rules engine that personalizes recommendations based on individual responses. As screenings can be conducted privately by individuals or during an appointment with a care provider, more individuals can be screened and referred to care. Once the referral is made, our system maintains transparency and accountability through a comprehensive audit trail that tracks all actions for compliance and review.
How Digital Tools Help Overcome Challenges
Health plans face significant challenges in meeting HEDIS measures for SUD treatment. It can be a struggle to reach and retain members after diagnosis, particularly given the stigma surrounding addiction that often leads to treatment reluctance. Compounding these issues are care coordination gaps across provider networks, data collection difficulties when tracking outcomes across multiple care settings, and documentation delays due to claims lag. Many plans also operate with limited care management capacity, lack specialized SUD expertise, and are unable to provide the round-the-clock support that members in crisis often need.
CHESS Health’s digital tools directly address these barriers by offering accessible, app-based solutions that members can use privately anytime, anywhere—reducing stigma and enabling individuals to assess their risk and seek help while remaining connected to the health plan. The platform’s robust data collection and tracking capabilities provide real-time visibility into member engagement and outcomes across all touchpoints, eliminating documentation delays and improving reporting accuracy. By supplementing clinical care teams with 24/7 peer-engagement support, including crisis intervention, CHESS Health amplifies provider capacity without requiring additional specialized staff, ensuring continuous member support that drives better engagement, retention, and ultimately, improved HEDIS measure performance.
Removing Barriers, Providing Opportunities
Health plans pursuing excellence in HEDIS measures for SUD care need scalable, data-driven solutions that bridge the gaps between clinical capacity and member needs. CHESS Health’s integrated digital platform transforms barriers to HEDIS compliance into measurable opportunities for improvement. By combining accessible screening tools with 24/7 peer support, closed-loop referral tracking, and real-time data visibility, CHESS Health’s solutions enable plans to engage members at every critical touchpoint.
This comprehensive approach doesn’t just help plans check compliance boxes; it strengthens the care infrastructure, ensuring members receive timely, consistent support while health plans gain the documentation and outcomes data needed to demonstrate quality. In a competitive and value-based healthcare landscape, CHESS Health solutions are an essential partner for health plans committed to advancing both their HEDIS performance and the well-being of the members they serve.
