Medicare

The Centers for Medicare & Medicaid Services (CMS) uses a risk adjustment process that is applied to payments made to Medicare Advantage Organizations (MAOs), which administer health plans for Medicare Advantage (MA) beneficiaries. This risk adjustment process creates risk scores designed to account for differences in health status among MA plan enrollees. Risk scores are calculated for all Medicare beneficiaries, regardless of whether the beneficiary was enrolled in Original Medicare (also known as Fee-For-Service Medicare) or MA during the payment year.

For a given payment year, the research risk score files include an Operational Payment Base File and Model Output Files (MOFs) from a mix of six potential risk models. The MOFs contain raw risk scores calculated prior to any adjustments made for payments. Each payment year has specific risk models that are based on that year’s risk adjustment methodology; payment years may use a blend of MOF risk scores as inputs to calculate the operational payment risk scores.

Depending on the payment year, the risk models that are used for MAO payments may include:

• ESRD V21 scores (based on model calibration year)
• Part C V21 scores
• Part C V22 scores
• Part C V23 scores
• Part C V24 scores
• Part D V05 scores

The table below lists the risk models used in each payment year's risk adjustment methodology:

Each MOF raw risk score file is based upon different model coefficients and different diagnosis code inputs for beneficiary clinical information, such as MA encounter data, Original Medicare claims, and the Risk Adjustment Processing System (RAPS), a predecessor system to encounter data collection. As a result, some MOFs will have more than one record per person because the risk model generates raw scores based on multiple sources of clinical diagnoses.

MOFs also contain Hierarchical Condition Categories (HCCs), which represent groups of diagnosis codes for related disease categories.

The research risk score files are designed to be used with other Chronic Conditions Warehouse (CCW) data products that contain a wide range of demographic and Medicare coverage information and can be linked to other CCW files using the Beneficiary ID variable.

What does this file include? (variable highlights)

• Model output raw risk scores
• Model-specific Hierarchical Condition Codes (HCCs/RxHCCs)
• Other model clinical and care setting indicators
• Model-specific disability information
• Demographic variables

Special considerations:

• Reference the CCW Medicare Risk Score Files User Guide for more information on the operational payment risk score base file and model output files.
• Reference the Report to Congress: Risk Adjustment in Medicare Advantage for a discussion of risk adjustment in the Medicare Advantage program.

The Centers for Medicare & Medicaid Services (CMS) uses a risk adjustment process that is applied to payments made to Medicare Advantage Organizations (MAOs), which administer health plans for Medicare Advantage (MA) beneficiaries. This risk adjustment process creates risk scores designed to account for differences in health status among MA plan enrollees. Risk scores are calculated for all Medicare beneficiaries, regardless of whether the beneficiary was enrolled in Original Medicare (also known as Fee-For-Service Medicare) or MA during the payment year.

For a given payment year, the research risk score files include an Operational Payment Base File and Model Output Files (MOFs) from a mix of six potential risk models. The MOFs contain raw risk scores calculated prior to any adjustments made for payments. Each payment year has specific risk models that are based on that year’s risk adjustment methodology; payment years may use a blend of MOF risk scores as inputs to calculate the operational payment risk scores. MOF risk scores are converted into payment risk scores by applying payment year specific CMS-Hierarchical Condition Category (HCC) risk adjustment model normalization factors and an MA coding pattern difference adjustment. The MA coding pattern difference adjustment is based on MA enrollment during the payment year and may not be appropriate for analyzing FFS cohorts.

The Risk Score Operational Payment Base File is a beneficiary-level data file with variables containing monthly risk adjustment payment scores. The file uses a beneficiary’s demographic, care setting, and clinical characteristics to identify the beneficiary’s correct monthly payment score, i.e., the monthly “operational” risk scores for each beneficiary which determine what CMS pays an MAO for that beneficiary.

The research risk score files are designed to be used with other Chronic Conditions Warehouse (CCW) data products that contain a wide range of demographic and Medicare coverage information and can be linked to other CCW files using the Beneficiary ID variable.

What does this file include? (variable highlights)

• Monthly Part C risk payment scores
• Monthly Part C model segment codes
• Monthly Part D payment risk scores
• Monthly Part D model segment codes
• Long-term institutional monthly indicators
• All possible Part C and Part D risk scores
• Beneficiary demographic characteristics

Special considerations:

• Reference the CCW Medicare Risk Score Files User Guide for more information on the operational payment risk score base file and model output files.
• Reference the Report to Congress: Risk Adjustment in Medicare Advantage for a discussion of risk adjustment in the Medicare Advantage program.

The KCC Model builds upon the earlier Comprehensive End Stage Renal Disease (ESRD) Care (CEC) Model structure, in which dialysis facilities, nephrologists, and other health care providers form ESRD-focused accountable care organizations to provide higher-quality, cost-effective care for beneficiaries with late-stage chronic kidney disease (CKD) and ESRD. CMS designed the KCC model to delay the onset of ESRD, better prepare patients for dialysis, coordinate care across different healthcare settings, and incentivize kidney transplantation.

What does this file include? (variable highlights)

• Participant Tax Identification Number
• Individual National Provider Identifier (NPI)
• CMS Certification Number
• KCC Model Participant Type
• Participant relationship to Kidney Contracting Entities under the KCC Model
• Participant information

Special Considerations

• This file can be linked to any other CMS file that includes the TIN, CCN, or NPI.
• The KCC Model Performance Period began on January 1, 2022, and will continue through December 31, 2027.
• For more information about the KCC Model, visit the CMS Innovation Center website or reference the CCW user guide. Questions about the model can be directed to KCF-CKCC-CMMI@cms.hhs.gov.

The KCC Model builds upon the earlier Comprehensive End Stage Renal Disease (ESRD) Care (CEC) Model structure, in which dialysis facilities, nephrologists, and other health care providers form ESRD-focused accountable care organizations to provide higher-quality, cost-effective care for beneficiaries with late-stage chronic kidney disease (CKD) and ESRD. CMS designed the KCC model to delay the onset of ESRD, better prepare patients for dialysis, coordinate care across different healthcare settings, and incentivize kidney transplantation.

What does this file include? (variable highlights)

• Beneficiary ID
• Beneficiary Demographic Information
• Alignment Start Date
• Beneficiary Monthly Kidney Disease Status
• Beneficiary Monthly Eligibility Status

Special Considerations

• This file can be linked to any other CMS file that includes the Beneficiary ID.
• The KCC Model Performance Period began on January 1, 2022, and will continue through December 31, 2027.

For more information about the KCC Model, visit the CMS Innovation Center website or reference the CCW user guide. Questions about the model can be directed to KCF-CKCC-CMMI@cms.hhs.gov.

This is an all-payer dataset completed for all patients receiving care in the LTCH including, but not limited to, Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries and includes condition categories used to calculate scores for LTCH quality measure data.

LCDS assessment records are submitted to the Centers for Medicare & Medicaid Services (CMS) from all Medicare certified LTCHs in accordance with the data submission requirements identified in the Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) Manual.

What does this file include? (variable highlights)

• Beneficiary ID
• Beneficiary demographic information
• Facility provider identifiers and location
• Admission and discharge dates
• Beneficiary diagnoses, functional status and other physical status information
• Beneficiary cognitive pattern assessment
• Use of medications in high-risk drug classes
• Selected procedures, treatments and programs

Special Considerations

• For more information about the LCDS, please see the LCDS Manual on the CMS website.

What does this file include? (variable highlights)

• State, county annual SSA codes
• State, county monthly FIPS codes
• Zip code, State and County
• Date of birth, date of death
• Race
• Reason for entitlement
• Monthly enrollment for each part of the Medicare program, A/B/C/D
• Dual eligible status
• Part C plan and enrollment information
• Part D plan and enrollment information
• Part D low income cost sharing
• Social Security disability status variables

The AHC Research Identifiable File (RIF) contains beneficiary-level screening and navigation information about individuals participating in the AHC model. Participants included Medicare and Medicaid enrollees, 94% of whom can be linked to other CMS research files. The remaining 6% cannot be linked to Medicaid or Medicaid claims, since their Medicare and/or Medicaid ID was either missing or incomplete.

The file contains data for the entire AHC Model performance period, which began on May 1, 2017 and concluded on April 30, 2023. Screenings were conducted between May 1, 2018, and January 31, 2023, and navigation services were provided to those with at least one health-related social need (HRSN) and two or more emergency department (ED) visits between May 3, 2018, and April 30, 2023.

The file includes one record per beneficiary screening, with some beneficiaries having more than one screening. For each beneficiary, screening outcomes across domains (e.g. food, housing, safety, transportation, utilities) are reported. Some beneficiaries also have supplemental indicators related to disabilities, education, employment, family and community support, mental health, physical activity, and substance use. For screened items where a need is identified, the file contains information about services offered and their outcomes.

What does this file include? (variable highlights)

• Person level identifiers (i.e., BENE_ID, MSIS_ID) that researchers can use to link to other CMS research files
• Sociodemographic variables (e.g., date of birth, race and ethnicity, education, income)
• HRSN screening results (e.g., HRSNs reported, number of ED visits in the 12 months prior to screening)
• Navigation case information for those who were eligible and opted in to receive navigation (e.g., navigation case start and end dates)
• Contacts between navigator and beneficiary who received navigation services (e.g., total number of successful contacts during the navigation period)
• Navigation outcomes (e.g., beneficiary reported connection with a community service provider, beneficiary had their HRSN(s) resolved)

Special Considerations

Most beneficiaries (94%) in the file have been linked to an identifier (BENE_ID and/or MSIS_ID) that researchers can use to link to other CMS research files. For more information on how to use the data, please refer to the Accountable Health Communities (AHC) Model Data File User Guide.