The risk adjustment model predicts plan liability for an average enrollee based on risk scores. CMS follows a claim data review process called the Risk Adjustment Processing System (RAPS) to review the information that has been submitted by all plans. Risk adjustment is a statistical process that considers the underlying health status and health spending of patients when examining their healthcare outcomes or healthcare costs. The Centers for Medicare and Medicaid Services is proposing to phase-in changes to the way it calculates risk adjustment payment to Medicare Advantage plans. On April 1, 2019, CMS published the 2020 Announcement, which finalized the use of the following risk adjustment models for PY2020: CMS-HCC (Part C) Risk Adjustment Models: The updated CMS -HCC alternative payment condition count model (i.e., 2020 CMS- HCC model) will be used to calculate the encounter data -based portion of the risk score. January 2019 ~ CMS has issued Part I of the Advance Notice of Methodological Changes for Calendar Year (CY) 2020 for the Medicare Advantage CMS-Hierarchical Condition Category (HCC) Risk Adjustment Model. Additional reconciliation run for CMS PY2020 Risk Adjustment data submission allows more time to close gaps and increase submission accuracy. 4. Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories. You can now sign in to submit your data for PY 2020. Performance Year 2020 Submission Window Is Open. The Centers for Medicare and Medicaid Services (CMS) has announced that they are supporting clinicians treating COVID-19 on the frontlines by "implementing additional extreme and uncontrollable circumstances policy exceptions and extensions" on reporting and data submission deadlines associated with the Merit-based Incentive Payment System (MIPS) and Medicare Shared … Guidance for Medicare Advantage Organizations, PACE Organizations, Medicare- Medicaid Plans, Section 1833 Cost Contractors and Section 1876 Cost Contractors, and Demonstrations of an upcoming deadline to submit risk adjustment data for use in calculating risk … The CMS-HCC risk adjustment payment model incorporates disease groups that have a significant impact on Part C expenditures. Return to Search. Submission of ambulatory risk adjustment data (physician and hospital outpatient) began on October 1, 2002 for dates of 2018 dates of service determine 2019 CMS risk score and payment) Raw Risk Score = Patient Demographic See 45 CFR § 153.20 for the definition of “risk adjustment covered plan”. You can submit and update your data any time until March 31, 2021 at 8 pm ET when the submission window closes. The draft CMS-HCC risk adjustment payment model was released on March 29, 2002. 6. purposes of BY 2020 risk adjustment data submissions, issuers of risk adjustment covered plans . 5. On September 18, 2020, the Department of Health and Human Services Centers for Medicare & Medicaid Services issued the following message regarding an additional PY 2020 Reconciliation Run in a memo: Also included with this notice are proposed changes in the payment methodology for CY 2020 for Part D and annual adjustments for CY 2020 to the Medicare Part D benefit parameters for the defined standard benefit. methodology and risk adjustment methodology applied under Part C of the Medicare statute for CY 2020. CMS Releases 2020 Medicare Advantage Risk Adjustment Payment Model. CMS will operate the risk adjustment program in all states in 2020. Medicare Advantage Risk Adjustment •CMS calculates factors for risk adjustment from Medicare Advantage and FFS claim data •Plans submit claims experience and encounter data •Prior year diagnoses are used for following year payments (i.e. From the claims and encounters submitted by the plan, CMS identifies the diagnosis (ICD-9-CM) codes that qualify for Hierarchical Condition Categories (HCC’s). See 45 CFR § 153.710(f)(1) and (f)(2). If an issuer fails the data quality analysis and is assessed a default charge under 45 CFR § 153.740(b) on that basis, Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation for Payment Year 2021.