The Impact of Health Risk Assessments on Risk-Adjusted Payments in Medicare Advantage

Under Medicare Part C, the CMS makes advanced monthly payments to Medicare Advantage (MA) organizations for each beneficiary enrolled. CMS risk-adjusts these payments based on beneficiaries' demographic information and clinical diagnoses from the prior year to pay MA organizations more for beneficiaries with higher expected costs. MA organizations submit to CMS encounter data, which are records of services provided to beneficiaries, including all diagnoses. Currently, CMS includes diagnoses from health risk assessments, which are visits to evaluate a beneficiary's health risks, when calculating risk scores and risk-adjusted payments. This is allowed regardless of whether these diagnoses are supported by another service rendered to the beneficiary during that year. This study will determine the extent to which diagnoses solely generated by health risk assessments were associated with higher risk scores and higher MA payments.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
Completed	Centers for Medicare & Medicaid Services	The Impact of Health Risk Assessments on Risk-Adjusted Payments in Medicare Advantage	Office of Evaluation and Inspections	OEI-03-17-00471	2020