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CMS Proposes Changes to CY 2021 Medicare Advantage Risk Adjustment Policies

For CFOs, government relations staff

This post has been archived and contains information that may be out of date.

The Centers for Medicare & Medicaid Services (CMS) has issued Part I of the calendar year (CY) 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies, proposing changes to the Part C CMS-Hierarchical Condition Categories (HCC) risk adjustment model as required by the 21st Century Cures Act, which mandates a 60-day comment period. Comments are due March 6.

Specifically, CMS proposes to continue to phase-in implementation of the risk adjustment model finalized for CY 2020 for payment to MA organizations, by calculating risk scores using 75% of the 2020 CMS-HCC model and 25% of the 2017 CMS-HCC model. Currently, CMS utilizes a blend of 50% of the 2020 CMS-HCC model and 50% of the 2017 CMS-HCC model.

In addition, CMS proposes to increase the use of encounter data — rather than diagnoses submitted to CMS’ Risk Adjustment Processing System (RAPS) by MA organizations — for calculating risk scores for payment. For CY 2020, CMS proposes to calculate risk scores for payment to MA organizations and certain demonstrations by summing 75% of the encounter data-based risk score with 25% of the RAPS-based risk score. Currently, CMS uses a blend of 50% encounter data and 50% RAPS data.

CMS intends to release Part II of the Advance Notice — which will include additional proposed payment methodologies that require a 30-day comment period — by Feb 6. A final MA rate announcement for CY 2021 is expected to be issued on or before April 6. Additional information is available in a CMS fact sheet.