Risk Score

RAPS - Risk Adjustment Processing System: 

·         Risk adjustment score is to calculate the "Plan Monthly Capitated Rate" - It is a fixed, pre- arranged monthly payment received by a physican, clinic or hospital per patient enrolled in a health plan with a captitated contract. 

·         Plan Monthly Capitated Rate will be calculated based on the current plan premium amount 

·         Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries.  

·         Risk Adjustment Processing System (RAPS) is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee.  

Risk Score Calculation: 

Calculation for setting capitation rates used for Medicare Advantage is based on cost(claims) data collected from fee-for-service providers. 

Risk Score Factors: Age, Gender, medicaid factor, Disease HCCs and Disability 

Hierarchical Condition Category (HCC): 

Risk scores are calculated using a new risk scoring methodology developed by CMS and called the HHS Hierarchical Condition Categories (HHS-HCC) model. 

This is distinct from the structurally similar CMS-HCC model used to risk adjust payments within the Medicare Advantage program. 

The HHS-HCC model uses diagnoses and demographics to assign a risk score to each individual. Each individual’s diagnoses are mapped to one of more than 100 condition categories. Additional logic is then applied to incorporate hierarchies into the mappings to ensure that an individual is classified into only the highest qualified cost category within a family of conditions.

RAPS to EDPS Transition: 

·         CMS has started the transition from the Risk Adjustment Payment System (RAPS) to the Encounter Data Processing System (EDPS) to establish risk adjusted payments for Medicare Advantage Organizations (MAOs). 

·         CMS is setting the rates on the fee-for-service equivalent pricing using “encounter data” submitted by Medicare Advantage Plans.  

EDPS Transition Percentage - Gradually:  

·         10/90 percent split in PY2016 (for 2015 dates of service) 

·         25/75 percent split in PY2017 

·         50/50 percent split in PY2018 

·         75/25 percent split in PY2019 

·         100 percent EDPS implementation in PY2020 

EDGE Server: It is also collecting data to calculate risk score for commercial plans. 

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