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member raf score

mbr_raf_scr
member·Updated Jun 12, 2026

Definition

ISO-11179 Definition

The Risk Adjustment Factor score calculated for an individual health plan member representing their predicted healthcare cost relative to the average Medicare beneficiary. RAF scores are calculated by CMS using the CMS-HCC model which combines demographic factors including age, gender, and enrollment status with diagnosis-based hierarchical condition category coefficients derived from submitted ICD-10 codes. A RAF score of 1.0 represents average expected cost, scores above 1.0 indicate higher predicted utilization, and scores below 1.0 indicate lower expected costs.

CMS multiplies the county-level base payment rate by the member RAF score to calculate monthly capitation payments to Medicare Advantage plans. Healthcare data teams store mbr_raf_scr as DECIMAL(10,3) in member risk score tables and use it in care management prioritization, network adequacy planning, and actuarial analysis.

Standard Abbreviation

mbr_raf_scr

Category

member

Production DDL — DIM_MEMBER

DIM_MEMBER.sql
CREATE OR REPLACE TABLE DIM_MEMBER (
    mbr_key           INTEGER        NOT NULL  -- surrogate key,
    mbr_id            VARCHAR(50)    NOT NULL  -- member identifier,
    mbr_first_nm      VARCHAR(100)             -- first name,
    mbr_last_nm       VARCHAR(100)             -- last name,
    mbr_birth_dt      DATE                     -- date of birth,
    mbr_gndr_cd       CHAR(1)                  -- gender code M/F/U,
    mbr_age           SMALLINT                 -- age in years,
    mbr_state_cd      CHAR(2)                  -- state code,
    mbr_zip_cd        VARCHAR(10)              -- zip code,
    mbr_elig_ind      BOOLEAN                  -- eligibility indicator,
    mbr_enrl_dt       DATE                     -- enrollment date,
    mbr_term_dt       DATE                     -- termination date,
    mbr_plan_cd       VARCHAR(20)              -- plan code,
    mbr_dual_elig_cd  VARCHAR(10)              -- dual eligibility code,
    load_dt           TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical member table. Convert to BigQuery or Databricks →

Why This Term Matters

Member and enrollment data governs who receives care and who pays for it — making it foundational to every downstream healthcare analytics workflow. Data engineers who understand member terminology build eligibility pipelines that prevent coverage gaps, correctly identify dual-eligible members, and support accurate risk adjustment submissions to CMS. Enrollment errors directly affect capitation payments and can trigger CMS corrective action plans.

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