Risk adjustment is a crucial component of Medicare Advantage (MA), ensuring that payments to MA plans reflect the health status and risk factors of their enrollees. As the MA population continues to grow, accurate risk adjustment becomes increasingly essential for effective care planning and financial sustainability.
With key changes occurring for MA plan benefits by the Centers for Medicare & Medicaid Services (CMS) for Contract Year (CY) 2026—including completing the three-year phase-in of updates to the MA risk adjustment model, updating the Part D risk adjustment model to account for Inflation Reduction Act-related changes, and more—health plans should prepare for these payment adjustments and their potential impact on plan offerings.
Enhancing accuracy through preparedness and dedicated planning
Accurate risk adjustment enables health plans to ensure appropriate funding for members with chronic conditions, which can support care planning and improve outcomes. By accurately capturing the complex conditions and specific needs of their MA enrollees, health plans can design targeted care interventions.
Read our white paper as we explore effective strategies to prepare your risk adjustment programs for upcoming changes, including:
- Aligning with providers to ensure proper documentation
- Implementing a comprehensive and ongoing evaluation framework to monitor operational and performance metrics
- Building tailored coding expertise to stay on top of market trends
- Leveraging combined technology and human expertise to drive impactful innovations
Effective risk adjustment for MA requires a multifaceted approach involving provider alignment, rigorous review processes, expert teams, up-to-date data management, and responsible use of technology. These efforts are essential for ensuring equitable care, optimizing financial performance, and ultimately improving the health and well-being of MA enrollees.
Join Cotiviti at RISE National 2025
To remain competitive in the digital age, plans should focus on improving data accuracy, operational efficiency, and provider and member experience as risk adjustment and quality improvement continue to evolve.
Join Cotiviti at RISE National 2025 to discover how to improve your results and enhance tech innovations with our risk adjustment and quality best practices. On March 13 and 14 during the conference breaks, talk one-on-one with us and gain the latest insights on:
- Driving retrieval and coding excellence in Medicare Advantage and Marketplace with me, Amanda Liu: Thursday, March 13 at 10:45 am and Friday, March 14 at 10:20 am
- Member engagement strategies for closing quality gaps with Leah Dewey: Thursday, March 13 at 1:45 pm
