CMS Risk Adjustments

Purpose

With the exception of PY 2014, CMS research files do not include beneficiary risk adjustment scores.  However, CMS does provide the programming code and instructions to calculate the three risk adjustments that CMS uses as the basis for managed care payment.

 

Current Version Date:
01/09/2017
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Often, researchers want to compare an individual to a similar group as a way to predict a certain outcome. One way to make the comparison is to calculate a risk adjustment score for each person based on factors such as age, gender and medical condition. The individual’s calculated risk score is compared to the average and used to predict an outcome (i.e. health care costs).

CMS uses risk adjustment as the basis for calculating managed care payment.  CMS provides programming code and descriptions for their risk adjustments on the CMS Risk Adjustment website.

  • Hierarchical condition category (HCC)
  • RxHCC
  • End Stage Renal Disease

Disclaimer:  ResDAC provides this information as a resource. ResDAC did not create the programming code and cannot provide technical support for it.

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Article Information

Author:
Faith Asper, MHS, CIPP/G
Level:
Introduction
Topic:
Analytic Guidance
Program:
Medicare
Category:
Medicare Encounter, Medicare Fee-For-Service Claims, Part D
Disclaimer:
The process and materials mentioned as part of this KnowledgeBase article are current, as of the publication date on the article, to the best of our knowledge. The examples provided are correct in the aggregate but may not apply to every subgroup or circumstance that a researcher may wish to study. It is up to the researcher to conduct analysis and confirm that the patterns described in this KnowledgeBase article apply to his/her particular study. If your research findings appear to contradict the advice provided, please contact ResDAC at resdac@umn.edu.