CMS Releases 2020 Medicare Advantage Risk Adjustment Payment Model

The Centers for Medicare and Medicaid Services (CMS) has proposed to phase-in changes to the way it estimates risk adjustment payment to Medicare Advantage plans, reports Healthcare Finance News . Beginning in 2020, CMS will calculate payments with a combination of 50 percent of the risk adjustment model first used for payment in 2017 and 50 percent of the new risk adjustment model proposed, but not finalized, in the 2019 rate announcement. The new model adds factors that count the number of conditions a beneficiary may have, including additional condition categories for mental health, substance use disorder, and chronic kidney disease. It also features technical updates such as calibrating the model with more recent data and selecting diagnoses with the same technique used for encounter data. Furthermore, CMS is presenting an alternate payment condition count model that includes additional condition categories for pressure ulcers and dementia. Under the 21st Century Cures Act, CMS must report to Congress on the Part C risk adjustment model and the end-stage renal disease risk adjustment model every three years, starting with a report due no later than Dec. 31. The initial report on risk adjustment in Medicare Advantage required by the 21st Century Cures Act is being issued at the same time as Part I of the 2020 Advance Notice.