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CMS HCC Risk Adjustment Model 2019: Winners & Losers


Our analysis finds there will be winners and losers at the plan level under the new models.

The Centers for Medicare & Medicaid Services (CMS) uses risk adjustment models to determine capitated payments made to Medicare Advantage (MA) plans and makes periodic updates designed to improve the performance of the models. A key component of the risk adjustment models is the set of Hierarchical Condition Categories that CMS uses to determine payments to MA plans.

This study assesses the impact of the most recent changes to the risk-adjustment models. Because 2019 payments will be affected by the changes, it is important for plans to understand now what the potential impact on their reimbursement may be in 2019 based on claims being submitted in 2018. MA plans can use the information provided in this report to better project how and where the changes will most impact their reimbursement based on the profile of their own beneficiary population.

For more information about this report or our analytic capabilities, connect with us.

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