PACE Medicare Risk Adjustment

The Centers for Medicare and Medicaid Services (CMS) has issued a memo notifying Programs of All-Inclusive Care for the Elderly (PACE), Medicare Advantage Organizations, Medicare-Medicaid Plans, Section 1833 and 1876 Cost Contractors, and Demonstrations of upcoming deadlines to submit risk adjustment data for use in calculating risk scores for Payment Years (PY) 2018, 2019, and 2020.

The first submission deadline is Sept. 7, 2018 and will cover dates of service from July 1, 2017 through June 30, 2018. The memo from the Medicare Plan Payment Group laying out the submission dates for 2018 through 2020 risk adjustment data is available here.

For PY 2018, CMS will apply a 15/85 blended risk score – 15 percent of the risk score will be calculated using diagnoses from encounter data and Fee-for-Service (FFS) claims, while 85 percent of the risk score will be calculated with diagnoses from the Risk Adjustment Processing System (RAPS) and FFS claims – for all 2018 calculations. For all PY 2019 calculations (initial, mid-year, and final), CMS will apply a 25/75 blended risk score – 25 percent of the risk score will be calculated with diagnoses from encounter data, FFS claims, and RAPS inpatient records and will be summed with 75 percent of the risk score calculated with diagnoses from RAPS and FFS.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841