The CMS Hierarchical Condition Categories (HCC) risk adjustment model predicts medical expenditures using demographics and diagnoses, where medical expenditures in a given year (risk score year) are predicted using diagnoses from the prior year (called the base year). The CMS-HCC model produces a risk score, which measures a person’s or a population’s health status relative to the average of 1.0, as applied to expected medical expenditures. For example, a population with a risk score of 2.0 is expected to incur medical expenditures twice that of the average, and a population with a risk score of 0.5 is expected to incur medical expenditures half that of the average.
Risk scores for attributed beneficiaries will be compared to the distribution of risk scores for all FFS beneficiaries in the same region who meet CPC+ eligibility requirements and who have had an eligible primary care visit. This group of beneficiaries is called the CMF reference population. Beneficiaries will be assigned to risk tiers on the basis of where their risk score falls within the regional distribution, as shown in the table below.
Risk Tier Criteria and CMF Payments (per Beneficiary per Month)
|Risk Tier||Attribution Criteria||Track 1||Track 2|
|Tier 1||1st quartile HCC||$6||$9|
|Tier 2||2nd quartile HCC||$8||$11|
|Tier 3||3rd quartile HCC||$16||$19|
|Tier 4||4th quartile HCC for Track 1; 75-89% HCC for Track 2||$30||$33|
|Complex(Track 2 only)||Top 10% HCC ORDementia||N/A||$100|