CMS Risk Score Payments to Health Plans

For Payment Year (PY) 2014, Centers for Medicare and Medicaid (CMS) used a blended model when calculating risk score payments to health plans by taking 25% of the 2013 HCC Model 12 and 75% of the 2014 HCC Model 22. (HCC = Hierarchical Condition Coding)

Although it was expected that CMS would fully phase in Model 22 by PY2015, CMS announced in the Final Call Letter on April 7, 2014 that the HCC blended model would continue.

For PY2015, CMS will use a blended risk score for each member by taking 67% of the 2013 HCC Model 12 and 33% of the 2014 HCC Model 22 each appropriately normalized.

http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/downloads/Announcement2015.pdf

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Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only.

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