Risk Adjustment Models
C
MS has developed separate risk adjustment models for the Parts A and B benefits offered by plans
under Part C and for the Part D benefits offered by Medicare Advantage Part D and prescription drug
plans. Within each benefit, CMS also segments each model, creating subpopulations with distinct cost
patterns.
Take some time to explore the models applicable to you and your work.
When you’re done exploring, select the Next button to learn about the similarities and differences
between the Part C and Part D models.
Part C (CMS-HCC NON-ESRD)
C
MS uses the Part C CMS-HCC model to calculate risk scores for beneficiaries who are not in
dialysis, transplant, or post-graft status. There are multiple segments associated with this model,
including the community, institutional, and new enrollee segments. For the Part C models
implemented in 2017 and beyond, there are six segments for community-residing beneficiaries,
one each depending on a beneficiary’s aged and disabled status and their dual eligible status –
whether they are full dual, partial dual, or non-dual. The Institutional segment is used to
calculate risk scores for individuals who are in long-term care institutions, including Skilled
Nursing Facilities (sniffs), for 90 days or more. New enrollee model segments are used for aged
and disabled beneficiaries who are new to Medicare or do not otherwise have enough diagnoses
to calculate a risk score – operationalized as those who do not have 12 months of Part B in the
data collection period. These new enrollee risk scores do not use diagnoses to predict costs and
use demographic factors only. There is also a segment for aged and disabled new enrollees in
Chronic Special Needs Plans, known as Chronic snips.