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Embracing CMS-HCC Model V28: A Strategic Approach for Health Plans by RAAPID

As the healthcare landscape evolves, the transition to the CMS-HCC (Hierarchical Condition Category) Model V28 represents a significant shift for health plans. RAAPID, a pioneer in healthcare technology solutions, is at the forefront of supporting health plans in navigating this transition. This blog provides insights into the CMS-HCC Model V28, its implications, and strategies for health plans to effectively adapt to these changes.

Understanding the CMS-HCC Model V28

The CMS-HCC Model V28, set to fully transition by 2025, introduces substantial changes in risk adjustment and reimbursement methodologies. This model is more refined, with an expanded number of HCCs (from 86 to 115), changes in ICD-10-CM to HCC mapping, and adjustments in coefficient values. These changes are based on updated fee-for-service data and aim to more accurately reflect recent utilization, coding, and expenditure patterns​​​​​​.

For health plans, this transition is crucial. The V28 model is expected to decrease Medicare Advantage risk scores by 3-8%, which translates to substantial changes in revenue and strategic planning. Health plans must proactively adapt to these changes to maintain financial sustainability and operational efficiency​​​​.

Strategic Planning for Health Plans

The phased transition to CMS-HCC Model V28 offers health plans the opportunity for strategic planning. RAAPID’s solutions, with our AI, ML, NLP, and knowledge graph technologies, are ideally suited to assist health plans in this transition. By leveraging our platform, health plans can:

  1. Accurately assess risk and ensure compliance with regulatory requirements.
  2. Proactively plan for anticipated changes in revenue and risk scores.
  3. Minimize operational disruptions and maintain focus on patient care and value-based partnerships.
  4. Gain a competitive edge by adapting early to the new model’s requirements​​.

The Impact of V28 on RAF Scores

The changes in CMS-HCC Model V28 will impact RAF (Risk Adjustment Factor) scores significantly. Notably, the model uses a constraining process where related HCCs are given the same coefficients. This could lower RAF scores for many patients, especially those with chronic conditions like diabetes. For health plans, this means a need for precise identification of HCCs and robust evidence retrieval from medical records​​​​.

RAAPID’s cloud-based solutions enable health plans to navigate these complexities by providing accurate chronic condition extraction and risk score calculation, critical for adapting to the V28 model.

Preparing for Challenges and Opportunities

The transition to V28 will pose challenges due to differences between the V24 and V28 models. Conditions classified as HCCs in one version may not be in the other, and even if they are, the RAF scores may differ. RAAPID’s technology supports health plans in identifying and analyzing the impact of these model differences, ensuring a smooth transition and continued compliance​​.


The CMS-HCC Model V28 represents a pivotal change in the risk adjustment landscape, with significant implications for health plans. RAAPID is dedicated to supporting health plans through this transition, providing innovative solutions that enable them to navigate these changes effectively. By partnering with RAAPID, health plans can confidently approach the CMS-HCC Model V28, optimizing their financial outcomes while delivering high-quality care to their members.

Explore RAAPID’s solutions today and ensure your organization is prepared for the CMS-HCC Model V28. Together, we can drive success in the era of value-based healthcare.


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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.