HCC RAF Score Calculator
Medicare Advantage risk adjustment · CMS-HCC Model V28
Patient Demographics
ICD-10 Diagnoses
No diagnoses added
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Base Payment Rate
Payment Impact
Per member · per month (PMPM)
Score Breakdown
Risk adjustment teams at health plans use Pro to model entire member cohorts and export RAF reports for actuary review.
- ✓ Unlimited calculations
- ✓ Save & compare up to 50 scenarios
- ✓ Export to PDF & Excel
- ✓ Track RAF scores over time
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What is HCC Risk Adjustment?
HCC (Hierarchical Condition Category) risk adjustment is the methodology the Centers for Medicare & Medicaid Services (CMS) uses to calculate risk-adjusted payments for Medicare Advantage health plans. The RAF (Risk Adjustment Factor) score represents a member's predicted healthcare costs relative to the average Medicare beneficiary.
- →A RAF score of 1.0 means average cost
- →A RAF score of 2.0 means twice average cost
- →A RAF score of 0.5 means half average cost
CMS multiplies the plan's base payment rate by the member's RAF score to determine the monthly capitation payment. Higher-risk members generate higher payments to the health plan to account for their expected higher utilization. This system ensures health plans are fairly compensated for enrolling sicker members and prevents cherry-picking of healthier beneficiaries.
Learn more in the HCC glossary entry and the RAF score definition.
How RAF Scores Are Calculated
RAF scores have two components that are summed to produce the final score:
1. Demographic component
Based on age, gender, and enrollment status (community vs. institutional vs. ESRD). Demographic coefficients are published annually by CMS in the Rate Announcement. Older members and institutionalized members carry higher demographic scores, reflecting their higher expected utilization.
2. Diagnosis component
Each qualifying ICD-10 diagnosis code maps to one or more HCC categories. Each HCC category has a coefficient published by CMS that adds to the RAF score. Hierarchies prevent double-counting — a more severe condition replaces a less severe one in the same disease group. Only the highest-severity HCC in each hierarchy is counted.
The CMS-HCC V28 model (used from 2024 payment year) contains 115 HCC categories across 23 disease groups. V28 replaced V24 for payment calculations starting in plan year 2024, with a 3-year blend period running through 2026 (50/50 blend in 2024, 33/67 in 2025, 100% V28 in 2026).
CMS-HCC V24 vs V28
CMS transitioned from V24 to V28 to better capture the complexity of modern chronic disease coding, particularly in behavioral health and substance use. Health plans should ensure their coding workflows capture the new categories added in V28.
| Feature | V24 | V28 |
|---|---|---|
| HCC categories | 86 | 115 |
| Disease groups | 24 | 23 |
| Payment year | Through 2025 blend | 2024+ |
| ICD-10 mappings | ~9,000 codes | ~10,500 codes |
| New categories | — | Mental health, SUDs |
What Affects RAF Scores
Key factors
- →Age — older members have higher demographic scores
- →Gender — females have different coefficients than males
- →Enrollment status — institutional > community
- →Dual eligibility — full duals have higher scores
- →Diagnosis codes — must be submitted annually to count
- →HCC hierarchies — more severe diagnoses replace less severe in the same category
- →Coding completeness — missed diagnoses result in lower RAF and underpayment to the plan
Common RAF score ranges
Frequently Asked Questions
What is a good RAF score for Medicare Advantage?
The average Medicare Advantage RAF score is approximately 1.0. Scores above 1.0 indicate higher than average predicted costs. Health plans with higher-acuity populations typically see average RAF scores of 1.2–1.8.
How often do RAF scores update?
CMS calculates RAF scores based on diagnosis data submitted during the prior calendar year. Plans submit diagnoses through RAPS and EDPS by the annual submission deadlines. RAF scores update when new diagnosis data is submitted or CMS recalculates.
What is the difference between CMS-HCC V24 and V28?
CMS-HCC V28 is the updated risk adjustment model introduced for payment year 2024. V28 expanded from 86 to 115 HCC categories, added new mental health and substance use categories, and updated ICD-10 mappings. CMS used a blended rate (50% V24 / 50% V28 in 2024, 33% / 67% in 2025, 0% / 100% in 2026).
How is RAF score used in Medicare Advantage payments?
CMS multiplies the county-level base rate by the member's RAF score to determine the monthly capitation payment. A member with RAF 1.5 in a county with a $900 base rate generates $1,350/month in revenue to the plan.
Can I use this calculator for official CMS submissions?
No — this calculator is for estimation and educational purposes only. Official RAF scores are calculated by CMS using complete diagnosis data submitted through RAPS and EDPS. Consult a qualified actuary and CMS documentation for official calculations.