What contributes to the Medicare Advantage enrollee risk score?

What contributes to the Medicare Advantage enrollee risk score?

Medicare adjusts payments to Medicare Advantage (MA) insurers using risk scores that summarize the relationship between fee-for-service (FFS) Medicare spending and beneficiaries’ demographic characteristics and documented health conditions.

What is MA risk adjustment?

Risk adjustment is used to adjust payments to Medicare Advantage Organizations (MAOs), Program of All Inclusive Care for the Elderly (PACE), certain demonstrations and Part D sponsors for the expected healthcare costs of their enrollees based on disease factors and demographic characteristics.

What is MMR in risk adjustment?

MARx uses the status to determine which Risk Adjustment Factor (RAF) is used to calculate a community beneficiary’s monthly payment and is included on the Monthly Membership Report (MMR).

How does Medicare Advantage risk adjustment work?

Risk adjustment is a statistical method that seeks to predict a person’s likely use and costs of health care services. It’s used in Medicare Advantage to adjust the capitated payments the federal government makes to cover expected medical costs of enrollees.

What is HCC risk score?

The CMS-HCC risk score for a beneficiary is the sum of the score or weight attributed to each of the demographic factors and HCCs within the model. The CMS-HCC model is normalized to 1.0. Beneficiaries would be considered relatively healthy, and therefore less costly, with a risk score less than 1.0.

What is CMS-HCC model V21?

In 2012, there was an update in the HCC model called version 21 (V21). In 2014 this model is used for PACE and ESRD enrollees. This updated model incorporated additional HCC conditions, different disease interactions, and different disabled HCC interactions terms to calculate a HCC score compared to the previous model.

How does risk adjustment work?

Risk adjustment modifies payments to all insurers based on an expectation of what the patient’s care will cost. For example, a patient with type 2 diabetes and high blood pressure merits a higher set payment than a healthy patient, for example. Watch Risk adjustment: An overview for providers.

How is RAF score calculated?

The amount the government pays is calculated by a formula—multiplying the government’s “county rate” by the patient’s risk adjustment factor or RAF score. County rate x RAF score = Monthly capitation rate.

How is HCC calculated?

How is risk score calculated Medicare?

The purpose of the Medicare risk scores is to estimate a relative cost factor. (i.e., it is a payment risk score). CMS calculates individual beneficiary-level risk scores by adding the relative factors associated with each beneficiary’s demographic and disease factors.

What is the average RAF?

A score of 1.00 is average, with the decimal places representing percentages above or below average. For example, if a plan’s average patient RAF score is 1.10, it will receive 10 percent more from Medicare.

What is RAF value?

A RAF score, or risk adjustment factor score, is a medical risk adjustment model used by the Centers for Medicare & Medicaid Services (CMS) and insurance companies to represent a patient’s health status. RAF scores are used to predict the cost for a healthcare organization to care for a patient.