SDoH screening under ACO REACH is a quality opportunity with a meaningful dollar figure attached, yet it is often managed as a once-a-year reporting task. Collecting that data from thousands of beneficiaries across dozens of affiliated practices on different EHRs doesn’t scale on spreadsheets and reminder calls.
The math changed for Performance Year 2026. CMS raised the ACO REACH quality withhold from 2% to 5%, so the SDoH data reporting submission, long known as Health Equity Data Reporting (HEDR), now carries more financial weight than before.
Mabel’s HEDR Survey tool was built for this kind of scaled outreach. This guide walks through what CMS requires and where manual processes tend to fall short.
What CMS Means by “SDoH Screening” in ACO REACH
SDoH screening asks about non-clinical factors, such as housing stability, food security, transportation, and utility needs, that shape health outcomes alongside clinical data. Under ACO REACH, that screening is tied to a CMS reporting requirement most ACOs know by its acronym.
Does the Screening Change Outcomes?
The requirement builds on CMS’s own research. The Accountable Health Communities (AHC) Model, which produced one of the screening tools REACH ACOs use for HEDR, ran as a CMMI test from 2017 to 2023 across 1.1 million Medicare and Medicaid beneficiaries.
Roughly 37% screened positive for at least one social need, and pairing screening with care navigation produced up to 7% lower Medicaid expenditures and 5 to 7% fewer avoidable ED visits and readmissions, for close to $200 million in savings, according to reporting on the model’s results. The takeaway: screening delivers the most value when it is paired with a way to act on what it finds.
Meet HEDR: The Acronym Behind the Adjustment
CMS has called this submission Health Equity Data Reporting, or HEDR. In its PY2026 materials, CMS refers to it simply as Data Reporting, calls the SDoH data Upstream Drivers of Health (UDOH), and accepts submissions through its Health Data Reporting (HDR) Application. Under the PY23 structure, ACOs could earn back up to 0.2% of the ACO Benchmark through it, as Mabel’s PY23 breakdown explains.
REACH ACOs submit beneficiary demographic and SDoH data during a defined post-performance-year window; PY23’s ran mid-January through mid-March 2024, per COPE Health Solutions.
The data feeds an ACO’s Total Quality Score. Based on CMS’s PY2026 quality measurement methodology, the Data Reporting adjustment can add up to 5 percentage points to an ACO’s Initial Quality Score. The adjustment is upward-only, documented declines count toward reporting credit, and demographic data no longer earns an adjustment in PY2026.
Why PY2026 Raises the Stakes
CMMI increased the ACO REACH quality withhold to 5% for PY2026, up from 2%, according to Milliman’s analysis of the changes. A higher withhold puts more benchmark dollars behind quality performance, with SDoH reporting one of the more controllable levers.
PY2026 is also ACO REACH’s final performance year, according to ATI Advisory, making this the last cycle to capture that adjustment under the model’s current rules.
Inside the SDoH Data Pipeline: From Screening to Submission
Understanding CMS’s requirements is the first step. Building a process that captures usable data across a real beneficiary population is the second, and CMS leaves most of those operational decisions to each ACO.
AHC, PRAPARE, or North Carolina: Pick One and Stick With It
CMS recognizes three standardized SDoH tools for HEDR submissions, and they aren’t interchangeable:
| Tool | Steward | Questions | Reading Level |
| AHC Health-Related Social Needs Screening Tool | CMS Accountable Health Communities Model | 19 social-needs questions (27 total) | 8th grade |
| PRAPARE | National Association of Community Health Centers | 17 social-needs questions, in 7 languages | 8th grade |
| North Carolina SDOH Screening Tool | NC Department of Health and Human Services | 11 questions | 5th grade |
Those differences matter operationally. The North Carolina tool’s shorter length and reading level generally finish faster in lower-literacy populations, while PRAPARE’s multilingual availability matters more in a network with non-English-speaking beneficiaries, per SIREN’s tool comparison.
The AHC tool also covers more ground than many ACOs expect: beyond its core questions on housing, food, transportation, utilities, and safety, it includes supplemental questions on substance use, mental health, and disability, per CMS’s screening tool.
Because those questions touch alcohol and drug use, ACOs should treat the responses as sensitive and confirm handling requirements with their privacy team. The stricter confidentiality rules in 42 CFR Part 2 generally apply to federally assisted substance use disorder treatment programs, so whether they apply depends on who collects and holds the data.
What Happens After a Beneficiary Says Yes or No
When a beneficiary declines or does not respond, CMS gives credit when the ACO documents the decline and the date of the collection attempt. CMS’s updated Data Reporting Implementation Guide (version 1.4, October 2026) explains how to record these beneficiaries on the submission template.
Responses collected via tablet, mailed form, or phone script then move into a submission file matching CMS’s ACO REACH Data Dictionary field definitions, with errors caught before submission rather than after rejection.
Where SDoH Screening Breaks Down at Scale
The requirements are clear on paper. In practice, multi-practice networks face a few common challenges.
Most REACH ACOs are networks of independent practices, each with its own EHR and workflow, which means training staff at every site and reconciling data formats never built to work together. Without central coordination, ACOs may not see their true completion rate until the deadline is close.
The second friction point shows up after collection: linking each response to the correct beneficiary, catching format errors before CMS does, and keeping an audit-ready record.
Mabel’s HEDR Survey tool addresses this with QC across provider- and beneficiary-specific data, reporting under 1% preventable rejections while processing 5,000 to 10,000 forms weekly at peak.
Turning HEDR From a Scramble Into a System
The practices below apply regardless of vendor. Each one treats HEDR as an ongoing process rather than a once-a-year form.
ACOs that perform well on HEDR treat it as a year-round priority, not a single submission event, according to Mabel’s analysis of PY24 HEDR performance. That means folding screening into visits already happening rather than running a separate campaign months later.
Response data needs to land in one place before submission. A shared dashboard surfaces completion gaps months in advance, which a folder of EHR exports cannot do.
Mabel in Practice: What 90% Completion in Two Weeks Looks Like
Where This ACO Started
One documented example shows what closing that gap looks like. An ACO REACH participant came to Mabel just weeks before its PY23 HEDR submission deadline, after struggling with manual, in-house outreach for its SDoH surveys, per Mabel’s HEDR success story.
Mabel’s HEDR Survey tool aggregated the ACO’s EMR data, added online SDoH surveys where EMR data didn’t exist, and mapped the dataset to CMS’s submission format via a real-time dashboard. The ACO reached 90% completion within two weeks and was positioned to capture its full $100,000 HEDR adjustment for PY23.
Nine ACOs, Not Just One
The broader pattern holds beyond this one ACO: nine ACO REACH participants using the tool cleared more than 90% of their PY23 HEDR adjustment, generating approximately $2 million in combined incremental profit. The difference was not beneficiary willingness. It was a process that kept responses from being lost between outreach and CMS submission.
The Last Cycle Before ACO REACH Sunsets
SDoH screening under ACO REACH is more than a data-collection exercise. It is a quality-score lever worth up to 5 percentage points, tied to a withhold that CMS more than doubled for the model’s final year. PY2026 data must be collected by December 31, 2026, and submitted between January 13 and March 17, 2027.
ACOs that approach HEDR as a year-end task often leave part of that adjustment unclaimed, because connecting screening to submission takes more coordination than it first appears.
If your ACO still coordinates SDoH screening through spreadsheets and individual practice outreach, Mabel’s HEDR Survey tool is built to close that gap between collection and CMS-ready reporting. Get in touch to see what that looks like for your beneficiary population.
Frequently Asked Questions
Is SDoH screening mandatory for beneficiaries in ACO REACH?
No. Beneficiary participation is voluntary, and ACOs may not require beneficiaries to report SDoH information. For the ACO, reporting is also optional, but it earns an upward quality adjustment of up to 5 percentage points, and documented declines count toward that credit, per CMS’s PY2026 quality measurement methodology. That’s why compliance teams should track outreach attempts rather than lean on response rate as the success metric.
Voluntary screening still calls for care. Screening conducted without awareness of the risk can retraumatize the beneficiary, according to the AMA Journal of Ethics, which recommends a genuine choice of format and being upfront about how answers will be used.
Can an ACO use more than one SDoH screening tool?
Yes, across the network, but never for the same beneficiary once a tool has been used to record their responses. CMS doesn’t mandate a specific collection method: an ACO can pull data from EMRs, a care-management assessment, or a standalone survey, per COPE Health Solutions.
Collection mode can also affect results. A meta-analysis of 48 samples and more than 125,000 respondents found computerized self-administered surveys draw meaningfully higher disclosure of sensitive information than paper self-administered ones, especially for substance-use questions, per Behavior Research Methods.
That bears directly on the AHC tool: a beneficiary answering on a tablet is more likely to disclose sensitive information honestly than one filling out the same questions on a mailed paper form.
How much is HEDR worth financially in PY2026?
The Data Reporting adjustment is proportional, not all-or-nothing. CMS scales the available 0-to-5 points to the share of an ACO’s aligned population it reports on, so an ACO reporting for half its beneficiaries earns roughly half the available points, per CMS’s PY2026 quality measurement methodology.
Because every reported beneficiary adds to the score, investment in outreach translates directly into quality points. With the PY2026 withhold at 5%, full reporting is worth about 0.25% of the benchmark.
The dollars behind it aren’t trivial: ACO REACH generated $2.51 billion in gross savings and $988.3 million in net savings to CMS across 115 ACOs in PY2024, up from $694.6 million the year before, per CMS’s PY2024 financial and quality results. Each ACO’s quality withhold earn-back is calculated on its own benchmark, so the value of the adjustment grows with the size of the ACO.
Is PY2026 the last year ACO REACH will require HEDR submissions?
Yes. PY2026 is the model’s final performance year, according to ATI Advisory’s analysis of the model’s sunset, and PY2026 data will be submitted in early 2027.
CMS has since named what comes next: the LEAD model, a 10-year voluntary model running January 1, 2027 through December 31, 2036, which CMS describes explicitly as ACO REACH’s successor. CMS hasn’t published LEAD’s SDoH requirements yet, so this is program-level context, not a guarantee HEDR carries over unchanged.
What happens if an ACO submits SDoH data in the wrong format?
CMS allows ACOs to correct errors during the submission window: it returns error files and accepts full replacement submissions. For PY2026, a Pre-Submission Validation Period runs January 5–12, 2027, ahead of the January 13 – March 17, 2027 submission window. That window doesn’t extend the deadline, so an ACO that discovers problems late has far less runway to fix them.
Catching errors early matters: because the adjustment is tied to reported population share, a batch rejected for formatting errors loses credit for every beneficiary caught in it.
