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On April 2nd, CMS released the Final Notice of Methodological Changes for Calendar Year 2019 for Medicare Advantage Capitation Rates, Part C and Part D Payment Policies. This document highlights the salient items affecting risk adjustments.
Model Changes Medical HCCs CMS will calculate risk scores with the updated CMS-HCC model without count variables. ESRD Model CMS will implement the updated ESRD dialysis and ESRD
functioning graft models as proposed in Part II of the
Advance Notice, published on February 1st.
Rx HCCs CMS will continue using the same RxHCC model used in Calendar Year 2018 with a normalization factor of 1.019. Formula Factor Changes
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HCC Code Changes Added three new Mental Health and Substance Use
Disorder HCCs: Drug Abuse, Uncomplicated, Except Cannabis HCC 56 Reactive and Unspecified Psychosis HCC 58
(current HCC 58 will change to HCC 59) Personality Disorders HCC 60
Added selected drug and alcohol poisoning (overdose) codes to existing Drug/Alcohol Dependence HCC 55
Added Chronic Kidney Disease Stage III HCC 135 Risk Adjustments from In-Home Assessments
There was no information regarding changes. Encounter Data as a Diagnoses Source for 2019 The 2019 risk score will be calculated by adding: 2018 dates of service from RAPS and FFS (75%) 2018 dates of service from EDS (supplemented with
RAPS inpatient data) and FFS (25%) New Medicare Card Project This is a reminder that the current Social Security Number based HICN will be replaced with a new Medicare number, the Medicare Beneficiary Identifier (MBI). During the transition period, 04/01/18-12/31/19, Medicare plans can use the HICN or the MBI to exchange data with CMS. For more information on the final regulations, please visit: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf
Factor Current CY2019 Impact
MA Coding Adjustment -5.91% -5.90% Positive
Normalization 1.017 1.038 Negative
ESRD Dialysis 1.015 1.033 Negative
Functioning Graft 1.082 1.048 Positive
F i n a l C a l l L e t t e r R i s k A d j u s t m e n t H i g h l i g h t s
We’re pleased to bring you this important insight.
Should you have any questions about this information, please do not hesitate to contact your Cognisight Account Manager or:
Jane Brownyard Director of Account Management 585.662.4285 [email protected]
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C ognisight is a leading health care solutions provider, specializing in risk adjustment
services for Medicare Advantage plans, Issuers on and off the Health Insurance Exchange,
PACE programs, and Medicaid Managed Care plans. Our mission is simple: capture the most
accurate and complete information to help ensure our clients have the best information to care for their
members.
As risk adjustment experts, we enable our clients to improve the quality of health care they
deliver while maximizing efficiency and assuring accurate revenue. Our continuum of comprehensive
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• Analytics • Health Assessments • IVAs • Provider & Coder Training
• Chart Reviews • RADV Support • Risk Verification
