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1, 2020, CMS will incorporate into its risk score calculation for MA plans an alternative payment condition model that includes additional Hierarchical Condition Category (HCC) codes for dementia: HCC51 Dementia With Complications and HCC52 Dementia Without Complications.
In the Advance Notice, CMS provides information and updates in accordance with the Star Ratings regulations at ? 422.164, 422.166, 423.184, and 423.186. In addition, CMS solicits input on future measures and concepts as we continue to advance health equity and enhance the Star Ratings over time.
Similar to the CMS-HCC risk adjustment model, the RxHCC model uses demographic characteristics and disease variables to predict costs. The RxHCC model predicts Medicare Part D plan liability costs for prescription drugs under the Part D program.
The CMS hierarchical condition categories (CMS-HCC) model, implemented in 2004, adjusts Medicare capitation payments to Medicare Advantage health care plans for the health. expenditure risk of their enrollees. Its intended use is to pay plans appropriately for their. expected relative costs.
There are three types of HCC review processes Prospective, Retrospective and Concurrent review.
In addition to the three major risk adjustment payment models already discussed, there are additional models that serve unique populations.Programs of All-inclusive Care for the Elderly (PACE)End-Stage Renal Disease (ESRD)Dual Eligible Special Needs Plans (D-SNPs)
An Introduction to Hierarchical Condition Categories (HCC)
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Hepatocellular carcinoma occurs most often in people with chronic liver diseases, such as cirrhosis caused by hepatitis B or hepatitis C infection.
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.
For 2020 there are 86 HCCs used to determine a patient's risk adjustment factor (RAF) score.