Georgia Medicare Risk Adjustment Payment Guide (2026)

The Georgia Medicare Risk Adjustment Payment methodology is the federal mechanism that determines how much CMS pays each Medicare Advantage plan for each enrolled Georgia beneficiary. Risk Adjustment is the foundation of MA capitation, the upstream calculation that every other MA payment component (Quality Bonus Payment, rebate retention, MLR compliance) modifies but does not replace.

By Brevy Care Team · Last verified May 22, 2026

What Medicare Advantage Risk Adjustment Payment Is

Risk Adjustment exists because beneficiaries differ significantly in their health status, and a plan covering a beneficiary with multiple chronic conditions faces materially higher expected costs than a plan covering a healthy beneficiary. Without risk adjustment, plans would have an incentive to selectively enroll healthier members (cherry-picking) and avoid sicker members. Risk Adjustment neutralizes that incentive by paying plans more for sicker members and less for healthier members, aligning plan payment with expected cost.

Risk Adjustment affects every Georgia Medicare Advantage enrollee because every enrollee's plan receives a risk-adjusted capitation payment based on that enrollee's individual health profile. The healthier the enrollee profile, the lower the capitation; the higher the disease burden (as captured by submitted diagnoses), the higher the capitation. This drives plan decisions about care management investment, provider documentation practices, member engagement initiatives, and benefit design.

The Risk Adjustment payment is calculated approximately as:

Plan Capitation = Benchmark × RAF Score × Geographic Adjustment + QBP Bonus + Rebate Retention

Where:

• RAF Score (Risk Adjustment Factor) is derived from the HCC model plus demographics
• HCC Model groups Hierarchical Condition Categories from ICD-10-CM diagnoses
• Benchmark is a county-specific Medicare benchmark set annually by CMS
• Geographic Adjustment reflects local input price adjustments

The Risk Adjustment methodology rests on:

• Section 1853 of the Social Security Act, the statutory authority for risk-adjusting MA capitation payments
• Federal implementing regulations at 42 CFR Part 422 establishing the HCC model framework, risk score calculation, data submission requirements, and reconciliation timeline
• The Balanced Budget Act of 1997, which created the Medicare+Choice program (predecessor to today's Medicare Advantage) and established the framework for risk-adjusting plan payments
• The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which significantly reformed MA risk adjustment and established the foundation for the current HCC model
• CMS annual rulemaking specifying HCC model coefficients, the V24-to-V28 transition phase-in, demographic adjustments, and methodology refinements

For Georgia eldercare specifically, Risk Adjustment matters because it determines how much your plan is paid for caring for you, which in turn determines how much your plan can invest in your benefits, your provider network access, your care management, and your member experience. A beneficiary who actively engages with their Annual Wellness Visit and ensures their chronic conditions are accurately documented helps their plan capture the appropriate RAF score, which sustains plan revenue and indirectly sustains the benefit package.

Why Risk Adjustment Matters in Georgia

Risk Adjustment matters in Georgia because:

A large share of Georgia MA enrollees have risk-adjusted capitation. Every Georgia Medicare Advantage enrollee's plan receives a capitation payment that has been adjusted upward or downward based on the enrollee's individual RAF score. This is foundational to MA economics. It is not a bonus or a penalty, it is the base payment itself.

Higher disease burden generates higher capitation. A beneficiary with diabetes, heart failure, and COPD generates substantially higher capitation than a healthy 65-year-old beneficiary. This is not arbitrary; it reflects the actual expected medical costs of caring for someone with that profile.

Provider documentation practices drive plan revenue. RAF scores depend on diagnoses captured during the data collection year. If a beneficiary has heart failure but it is not documented in their medical record during a face-to-face encounter that calendar year, the plan cannot claim it for risk adjustment. Provider documentation practices, whether the provider takes time to thoroughly assess and document chronic conditions during visits, directly affect plan revenue.

Annual Wellness Visits matter. The Medicare Annual Wellness Visit (AWV) is a covered preventive benefit that includes a comprehensive health risk assessment and review of chronic conditions. For Risk Adjustment purposes, the AWV is one of the most important visits each year because it is a structured opportunity to ensure all chronic conditions are accurately documented.

Risk Adjustment integrates with QBP and MLR. The risk-adjusted capitation flows through MLR (as part of the premium revenue denominator) and is multiplied by the Medicare Advantage Quality Bonus Payment (QBP) bonus (as part of total plan revenue). The three regulations (Risk Adjustment plus MLR plus QBP) form the plan-economics triad that determines how MA plans operate in Georgia.

RADV audits ensure accuracy. CMS Risk Adjustment Data Validation (RADV) audits validate submitted diagnoses against medical records. Plans face recoupment of overpayments for diagnoses that are not supported by medical record documentation. RADV creates pressure for accurate documentation, not just maximizing submissions.

V24 to V28 model transition is changing the economics. CMS is phasing in a refined HCC model (V28) over a multi-year transition. V28 reduces coefficient inflation, refines HCC definitions, and is less susceptible to manipulation. Georgia plans are adapting their care management and documentation strategies in response.

For Georgia eldercare specifically:

• A substantial share of Georgia Medicare beneficiaries are enrolled in Medicare Advantage, with risk-adjusted capitation
• All major Georgia MA carriers (Humana, UnitedHealthcare, Aetna, Anthem, Wellcare, Cigna, Kaiser Permanente Georgia, Alignment Health Plan, Devoted Health) are subject to risk adjustment
• GeorgiaCares SHIP provides free Risk Adjustment education
• Georgia Senior Medicare Patrol monitors diagnosis upcoding fraud (false diagnoses submitted to inflate risk scores)

Federal Legal Framework

The Risk Adjustment methodology rests on the following federal statutory and regulatory framework:

Section 1853 of the Social Security Act. Provides statutory authority for CMS to risk-adjust MA capitation payments based on the health status of enrollees, and authorizes CMS to use demonstration authority to implement risk adjustment methodologies and to modify them over time.

Federal implementing regulations at 42 CFR Part 422. Specifies the risk adjustment implementing regulations, including the HCC model framework, the calculation of risk scores, the data submission requirements, the encounter data submission requirements, the RADV audit framework, and the annual reconciliation timeline.

Balanced Budget Act of 1997. Created the Medicare+Choice program (predecessor to today's Medicare Advantage) and established the framework for risk-adjusting plan payments.

Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Significantly reformed MA risk adjustment and established the foundation for the current HCC model.

CMS Annual Rate Announcement and Call Letter. Each year, CMS publishes detailed risk adjustment parameters including the HCC model coefficients, the V24-to-V28 transition phase-in, demographic adjustments, and any methodology refinements.

CMS HCC Risk Adjustment Model V24. The legacy production model, used during the V28 phase-in period. V24 covers Hierarchical Condition Categories derived from ICD-10-CM diagnoses.

CMS HCC Risk Adjustment Model V28. The refined model phasing in over a multi-year transition, with refined HCC definitions, reduced coefficient inflation, and more accurate risk capture.

Encounter Data Submission (EDS). Plans must submit encounter-level data to CMS through the EDS system. The legacy Risk Adjustment Processing System (RAPS) has been sunset.

RADV audit framework. Codified in 42 CFR Part 422 implementing regulations.

The CMS HCC Risk Adjustment Model

The CMS Hierarchical Condition Categories (HCC) Risk Adjustment Model is the core analytical framework that translates diagnoses into a risk score. Key features:

Hierarchical Condition Categories. Diagnoses from ICD-10-CM are grouped into HCCs. Each HCC represents a clinically coherent disease grouping with similar expected cost implications.

Disease Hierarchies. Within disease families, more severe HCCs override less severe ones to prevent double-counting. For example, if a beneficiary has both simple diabetes and diabetes with complications, only the more severe HCC counts. The hierarchy prevents inflating scores by stacking related codes.

Demographics. Age, gender, and Medicaid status feed into the risk score alongside HCCs. A 90-year-old female with the same HCCs as a 65-year-old male will generate a different RAF score.

Disabled and ESRD Adjustments. Beneficiaries who qualify for Medicare via disability (under age 65) or who have End-Stage Renal Disease get special treatment in the model to reflect their distinct cost profiles.

Population Segments. The model has separate segments for:

• Community Non-Disabled (most beneficiaries)
• Community Disabled (under-65 disabled)
• Long-Term Institutional (nursing home residents)
• Working Aged (employed beneficiaries with employer coverage as primary)

Each segment has its own coefficients reflecting distinct cost patterns.

The Risk Score Calculation Process

The Risk Adjustment calculation operates on a specific data collection and submission cycle:

Step 1: Diagnoses captured during data collection year

Diagnoses are captured from:

• Hospital inpatient encounters, admissions with discharge diagnoses
• Hospital outpatient encounters, observation, ED visits, outpatient surgery
• Physician encounters, face-to-face evaluations, including AWVs

The diagnosis must be:

• Documented in the medical record
• Captured during a face-to-face encounter
• Coded to ICD-10-CM specificity
• Submitted to CMS via Encounter Data Submission (EDS)

Telephone-only encounters historically did not qualify for risk adjustment, though CMS has periodically adjusted policy around telehealth. Confirm current telehealth eligibility in the current CMS rulemaking.

Step 2: Plans submit via Encounter Data Submission (EDS)

Plans submit detailed encounter-level data to CMS through the EDS system. The legacy Risk Adjustment Processing System (RAPS) has been sunset; EDS is now the sole submission pathway.

Step 3: Annual sweep

CMS conducts annual sweep cycles where plans can submit additional encounter data with the original data collection year. The final sweep deadline is set by CMS annual rulemaking; confirm the current-year deadline in the active CMS Rate Announcement.

Step 4: CMS calculates RAF score

CMS aggregates submitted diagnoses, applies the HCC model hierarchies, adds demographic factors, and produces a final RAF score for each beneficiary.

Step 5: Capitation adjusted retrospectively

The plan's capitation is reconciled. If more diagnoses were submitted in the final sweep, the plan receives a retroactive payment adjustment. If fewer diagnoses are validated by RADV, the plan repays.

Data Collection Year vs Payment Year

A critical timing convention to understand:

• Diagnoses collected in calendar year T
• Drive plan payments in calendar year T+1
• Final reconciliation by CMS-specified deadline following the payment year

This convention means there is a lag between when a beneficiary's health is documented and when the plan's payment reflects it. It also means plans cannot capture diagnoses in real-time to immediately raise capitation; they must build the documentation through the data collection year for the following year's payment.

V24 vs V28 Model Transition

CMS is phasing in the V28 model over a multi-year transition, replacing the V24 model. CMS annual rulemaking specifies the blend weights for each transition year; consult the current CMS Rate Announcement for the operative percentages.

The V28 model refinements include:

• Refined HCC definitions. Some V24 HCCs have been narrowed or restructured to reflect more accurate cost patterns.
• Reduced coefficient inflation. Some V24 coefficients were inflating risk scores beyond actual cost; V28 corrects.
• More accurate risk capture. Better differentiation between high-cost and low-cost variants of similar conditions.
• Less manipulation susceptibility. Some V24 patterns that incentivized aggressive coding have been adjusted.

The transition affects plans differently depending on their member mix and documentation patterns. Plans heavily reliant on certain HCCs (e.g., certain musculoskeletal or psychiatric codes that V28 deflates) face revenue headwinds. Plans focused on appropriate clinical management generally see modest changes.

For Georgia beneficiaries, the V24/V28 transition manifests indirectly, through plan benefit and premium decisions in following ANOCs as plans adjust to the new economics.

RADV Audits, Risk Adjustment Data Validation

Risk Adjustment Data Validation (RADV) is the audit framework CMS uses to validate plan-submitted diagnoses. Key features:

• Sample-based audits. CMS selects a sample of beneficiaries from each plan.
• Medical record review. CMS requests medical records supporting the submitted diagnoses.
• Validation criteria. Diagnoses must be supported by documentation in a face-to-face encounter during the data collection year.
• Recoupment. Unsupported diagnoses result in recoupment of associated overpayments.
• Plan-level extrapolation. CMS has authority to extrapolate findings from the audit sample to the full plan population (this has been the subject of significant litigation).
• Fee-for-service adjuster. Historically, RADV applied an FFS adjuster to account for similar coding patterns in Original Medicare; CMS has been adjusting this policy.

For Georgia beneficiaries, RADV occasionally manifests as:

• A medical record request from your provider (the plan needs the record to support a submitted diagnosis)
• A request to confirm a diagnosis was discussed during a recent visit
• Communications from your plan about the importance of accurate documentation

These activities are part of the plan's RADV compliance work, not direct beneficiary obligations. You do not need to respond to plan requests about your diagnoses unless they directly affect your care.

How Risk Adjustment Coordinates with QBP

Risk Adjustment and QBP are sequential components of MA capitation:

1. Base capitation equals the county benchmark times the geographic adjustment
2. Risk adjustment multiplies by RAF score to produce risk-adjusted capitation
3. QBP bonus adds a bonus percentage for qualifying high-star plans (with a higher bonus for double-bonus counties); consult the current CMS Rate Announcement for operative percentages
4. Rebate equals (benchmark minus bid) times the retention percentage and funds supplemental benefits

A high-star MA plan in a double-bonus county covering a beneficiary with multiple chronic conditions receives a higher per-member-per-month payment because all three components (benchmark, RAF score, QBP bonus) work in the plan's favor. A standard-star plan in a standard county covering a healthy beneficiary with a below-average RAF score receives a lower per-member-per-month payment because RAF is below 1.0 and no QBP bonus applies.

The combination of risk adjustment and QBP creates substantial variation in plan revenue, which explains differences in benefit packages, network breadth, and care management investment.

How Risk Adjustment Coordinates with MLR

The federal Medical Loss Ratio (MLR) floor for MA plans operates on premium revenue, which includes risk-adjusted capitation. Specifically:

MLR Denominator equals Premium Revenue minus Taxes and Fees.

Premium revenue includes:

• CMS risk-adjusted capitation
• Beneficiary premiums
• Quality bonus payments
• Other CMS payments

So risk adjustment flows into the MLR calculation: higher risk-adjusted capitation means higher premium revenue denominator, which means larger required clinical and QIA spending to meet the federal MLR floor.

A plan that captures appropriate RAF scores has:

• Higher premium revenue
• Higher required clinical and QIA spending
• More resources available for QIA investment
• Better positioning for Star Ratings (and thus QBP)

The three regulations align: accurate risk adjustment generates adequate premium revenue, which supports MLR compliance and QIA investment, which improves Star Ratings, which captures QBP, which funds richer supplemental benefits and supports member retention.

How Risk Adjustment Coordinates with the Bid Process

In the MA bid process, plans bid on a standardized risk score and CMS later risk-adjusts actual payments up or down based on actual enrollee mix. The bid deadline is set by federal regulation; consult the current CMS bid instructions for the operative date.

This means:

• The bid is a standardized projection
• Actual payment is risk-adjusted
• Plans take on risk for the difference

If a plan's actual enrollee mix is sicker than the bid assumed, CMS pays more via risk adjustment. If the actual mix is healthier, CMS pays less. This shifts risk between CMS and plans and creates incentives for plans to:

1. Accurately project the expected enrollee mix
2. Capture documentation thoroughly to ensure actual diagnoses are reflected in RAF scores
3. Manage care effectively to control costs even when diagnoses are present

Operational Implications for Georgia Beneficiaries

What does Risk Adjustment mean for Georgia MA beneficiaries practically?

1. Annual Wellness Visit (AWV)

Schedule your AWV each calendar year. The AWV is:

• Covered with no copay and no deductible under Medicare preventive benefits
• A structured visit reviewing your health history, chronic conditions, medications, and prevention recommendations
• One of the most important visits each year for Risk Adjustment purposes, because chronic conditions are reviewed and documented

The AWV is different from an annual physical exam (which may have cost-sharing) and from sick visits (which address specific complaints).

2. Comprehensive Documentation of Chronic Conditions

When you visit your PCP or specialists, ensure your chronic conditions are discussed and documented during the visit:

• Diabetes
• Heart failure
• COPD
• Chronic kidney disease
• Cancer history (active or in remission)
• Mental health conditions
• Other persistent conditions

If a condition is not documented during a face-to-face visit in the calendar year, the plan cannot claim it for risk adjustment that year. The chronic condition recapture workflow that many plans encourage is not a billing trick, it is a documentation requirement.

3. Avoid Diagnosis Upcoding Fraud

Be alert to providers or marketers who:

• Suggest you have conditions you do not actually have
• Submit diagnoses based on questionnaires alone without clinical evaluation
• Pressure you into in-home risk assessments that seem more focused on documentation than care

These patterns can constitute diagnosis upcoding fraud. Report to Georgia Senior Medicare Patrol.

4. Engage with In-Home Health Risk Assessments Thoughtfully

Many MA plans offer in-home Health Risk Assessments (HRAs). These can be genuinely helpful for care planning, but they also serve a documentation purpose. Engage but watch for signs that the HRA is solely focused on submitting diagnoses without delivering care.

5. Understand Care Management Programs

Disease management programs (diabetes, heart failure, COPD) serve multiple purposes:

• Care benefit for you
• Documentation pathway for chronic conditions
• QIA spending counting toward MLR
• Star Rating improvement
• Risk Adjustment recapture

These are aligned with your interests. Participation generally helps you AND helps your plan.

Best Practices for Georgia Beneficiaries Around Risk Adjustment

1. Schedule your Annual Wellness Visit each calendar year. This is the single most important Risk Adjustment-related visit. Covered with no cost-sharing.

2. Bring a current medication list and condition list to every visit. Help providers efficiently document chronic conditions.

3. Discuss all chronic conditions at PCP visits, not just the acute issue you are being seen for. Documentation needs to happen during face-to-face encounters in the calendar year.

4. Engage with chronic condition management programs offered by your plan. They serve your care needs and support accurate documentation.

5. Don't ignore plan outreach about in-home assessments, but evaluate them critically. Genuine care assessments are valuable; pure documentation visits without care are red flags.

6. Report aggressive documentation pressure (providers or marketers suggesting you have conditions you do not have) to Georgia Senior Medicare Patrol.

7. Use the same PCP year-over-year when possible. Continuity supports accurate longitudinal documentation.

8. Ensure ESRD or disability status is documented if applicable. These trigger special model segments with different coefficients.

9. Update your plan when you have new diagnoses. Make sure your plan's medical records align with new conditions identified at outside providers.

10. Don't avoid medical visits to stay healthy for plan purposes. Underutilization is not beneficial; appropriate care is.

11. Verify your plan's network includes your providers before AEP changes. Continuity supports both your care and risk adjustment workflows.

12. Ask GeorgiaCares SHIP if you have questions about how risk adjustment affects your plan. Free counseling.

13. Read your plan's ANOC each September. Plan revenue dynamics (including Risk Adjustment) drive benefit changes year-over-year.

14. Stay engaged with annual care. Risk Adjustment captures the conditions you have through annual face-to-face documentation. Skipping years means lost capture.

Common Risk Adjustment Issues Georgia Beneficiaries Face

1. "My plan keeps calling about an in-home assessment." Often a Risk Adjustment-related documentation effort. Genuine care components have value; pure documentation visits do not. Discuss with your PCP whether participation makes sense.

2. "My provider didn't document my heart failure." Bring up chronic conditions explicitly during visits. Providers cannot document what is not discussed or assessed.

3. "A marketer suggested I have diabetes when I don't." Diagnosis upcoding fraud. Report to Georgia SMP.

4. "What's the difference between AWV and annual physical?" AWV is preventive, covered without cost-sharing, focused on health risk assessment and care planning. Annual physical may have cost-sharing and is a more comprehensive clinical exam. Both can document chronic conditions; AWV is structured for risk adjustment purposes.

5. "My plan offered me a gift card to do a HRA." Plans may incentivize HRA participation. Evaluate whether the HRA includes meaningful care components or is pure documentation.

6. "My provider rushes through visits, I worry conditions aren't documented." Bring written notes about chronic conditions. Ask explicitly if the visit will include review of chronic conditions.

7. "What's V28 and should I care?" V28 is CMS's refined HCC model phasing in over a multi-year transition. You do not need to track V28 directly, it affects plans, not beneficiaries, though it may indirectly drive ANOC changes.

8. "My plan asked for medical records." Likely a RADV audit response. Your provider sends the records; you do not need to provide them yourself.

9. "I have ESRD, does this affect my Medicare?" Yes. ESRD beneficiaries can enroll in MA plans (per a federal expansion in recent years) and trigger special Risk Adjustment model treatment. Talk with GeorgiaCares SHIP.

10. "I'm under 65 and on Medicare via disability." You are in the Community Disabled segment of the HCC model. Your RAF score will be calculated using disabled coefficients.

11. "I missed my AWV last year." Schedule one for this year. Don't worry about catching up, the focus is annual ongoing documentation.

12. "My chronic condition isn't on the plan's HRA form." Mention it explicitly. The form is structured but providers can document conditions beyond the form.

13. "How does Risk Adjustment relate to my premium?" Indirectly. Higher plan capitation (from accurate RAF capture) sustains lower beneficiary premiums and richer supplemental benefits. Your RAF score is not itself your premium.

14. "My plan's marketing claims they get paid more for caring for sicker members so they're better at it." Marketing claims should be evaluated critically. Risk Adjustment does pay plans more for sicker members, but that does not automatically mean better care. Evaluate plans on Star Rating, network, formulary, and benefits.

Worked Examples

Example 1: Fulton 67 Margaret, AWV and Chronic Condition Recapture

Margaret, age 67, lives in Atlanta (Fulton County) and is enrolled in a high-star MA plan. Her plan sends a reminder that she should schedule her Annual Wellness Visit. Margaret schedules the AWV with her PCP.

During the AWV, the PCP reviews:

• Her history of well-controlled hypertension
• Her history of type 2 diabetes
• Her family history of cardiovascular disease
• Her medications (lisinopril, metformin, atorvastatin)
• Preventive care recommendations (mammogram, colonoscopy)

The PCP documents the diabetes and hypertension in the encounter. This documentation enables the plan to claim Margaret's diabetes for Risk Adjustment in the next payment year.

Margaret also discusses sleep issues and an occasional cough. The PCP appropriately evaluates but does not add diagnoses without clinical evidence. Margaret's RAF score reflects her actual disease burden, appropriate, not inflated.

Example 2: DeKalb 70 James, Multiple Chronic Conditions Driving Capitation

James, age 70, lives in DeKalb County and has:

• Type 2 diabetes with complications
• Heart failure (NYHA Class II)
• COPD
• Chronic kidney disease stage 3
• Cancer (prostate, in remission 5 years)

His RAF score is well above average, reflecting substantial expected medical costs. His MA plan receives correspondingly higher capitation.

James engages actively with:

• Quarterly PCP visits ensuring all conditions are documented annually
• His plan's heart failure management program (nurse check-ins, weight monitoring)
• His plan's diabetes care management program
• Annual cardiology and nephrology follow-ups

The plan's higher capitation funds these care management programs, which serve James's care needs and support his condition stability. James's RAF score is not a tax on him, it is the appropriate payment for his actual care needs.

Example 3: Cobb 68 Robert, Newly Diagnosed Condition Affecting Plan Revenue

Robert, age 68, lives in Cobb County and is enrolled in a 4-star MA plan. In April, he is diagnosed with type 2 diabetes following an elevated A1C at his PCP visit.

The PCP documents the new diabetes diagnosis in the encounter. This will be submitted to CMS via EDS and will contribute to Robert's RAF score for the next payment year.

The plan's diabetes management program reaches out within a week:

• Connection to a certified diabetes care and education specialist
• Free glucose monitor and strips
• Annual diabetic eye exam reminders
• Medication management support
• Nutrition counseling

Robert engages with the program. The care benefit is real, and the plan's investment is supported by the higher capitation it will receive in the following payment year due to accurate Risk Adjustment capture.

Example 4: Worth County 72 Linda, Rural Beneficiary Documentation Gaps

Linda, age 72, lives in Worth County (rural South Georgia). She has hypertension and osteoarthritis, but hasn't seen her PCP in 18 months due to transportation challenges and a desire to stay out of medical settings.

Her MA plan reaches out with multiple options:

• Telehealth visit (Medicare-covered)
• Plan-arranged transportation to PCP
• In-home Annual Wellness Visit through partnered provider

Linda calls GeorgiaCares SHIP to evaluate the options. The counselor explains:

• Telehealth and in-person AWVs are both legitimate
• The in-home AWV through plan-partnered provider is genuine if it includes comprehensive health assessment, not just documentation
• Transportation arrangement is a legitimate plan benefit
• Linda should pick the option most likely to result in meaningful care, not just documentation

Linda schedules a plan-arranged transportation to her regular PCP for AWV. Her conditions get documented, she receives care, and the plan captures appropriate Risk Adjustment.

Example 5: Bibb 69 David, RADV Audit-Related Medical Record Request

David, age 69, lives in Macon (Bibb County) and is enrolled in a 4-star MA plan. He receives a letter from the plan asking him to confirm that he discussed his heart failure with his PCP at a March visit.

David is confused. He calls GeorgiaCares SHIP. The counselor explains:

• This is likely a RADV-related verification
• The plan is confirming the documentation supports the submitted heart failure diagnosis
• David should confirm with his PCP whether heart failure was discussed and documented
• David does not need to provide medical records himself; the plan and PCP handle that

David calls his PCP's office. The PCP confirms heart failure was discussed and is documented in the chart. David tells the plan he confirms heart failure was discussed. The plan completes the verification.

Example 6: Hall 65 Sarah, V28 Transition Timing Impact

Sarah, age 65, lives in Hall County (Gainesville area). She turns 65 in March and enrolls in a 4-star MA plan during her IEP. She notices that the plan's supplemental benefits are slightly leaner this year compared to what was offered last year.

Sarah calls GeorgiaCares SHIP. The counselor explains several factors potentially driving the benefit changes:

• V24-to-V28 risk adjustment model transition is reducing some plan revenue
• Star Ratings may have shifted (check for status)
• Medical trend (general healthcare cost growth)
• Plan strategic decisions

The counselor notes that V28's reduced coefficient inflation generally lowers Risk Adjustment revenue per member, especially for plans heavily reliant on certain HCC patterns. Plans are adjusting benefits to accommodate the new economics over the multi-year phase-in.

Sarah selects the plan, recognizing that the slightly leaner benefits reflect broader industry economics, not plan failure. She schedules her AWV and engages with the plan's care management programs.

A few more common questions Georgia beneficiaries ask:

Does my RAF score affect my premium? Not directly. Your RAF score affects how much CMS pays your plan, which indirectly affects plan revenue and thus benefits, premiums, and cost-sharing.

What is the HCC model? The CMS Hierarchical Condition Categories model, the analytical framework that groups ICD-10-CM diagnoses into condition categories with disease hierarchies. The HCC model translates raw diagnoses into a structured risk score.

What's the difference between V24 and V28? V24 is the legacy production HCC model. V28 is the refined model phasing in over a multi-year transition with refined HCC definitions, reduced coefficient inflation, and more accurate risk capture. The current period uses a blended V24/V28 calculation per CMS annual rulemaking.

Can a provider add diagnoses without examining me? No. Diagnoses for risk adjustment must be supported by face-to-face encounter documentation with clinical assessment. Adding diagnoses without examination is potentially fraudulent.

What is an Encounter Data Submission (EDS)? The CMS system through which plans submit encounter-level data. EDS replaced the legacy Risk Adjustment Processing System (RAPS).

What is the annual sweep? CMS's annual reconciliation cycle for risk adjustment data. The final sweep deadline is set by CMS rulemaking; confirm the current-year deadline in the active CMS Rate Announcement. Plans can submit additional encounter data through this period.

Will RADV affect my care? No. RADV affects plan payments, not beneficiary care. You may receive communications from your plan or provider about medical record verification, but it does not change your benefits or care.

Does my plan get paid more for sicker members? Yes. Risk Adjustment pays plans more for members with higher disease burden, reflecting expected higher medical costs. This is structural; without risk adjustment, plans would have an incentive to enroll only healthy members.

What if my provider doesn't document my chronic conditions? Bring written notes about your conditions to visits. Ask explicitly that chronic conditions be reviewed. If your provider consistently fails to document, consider whether the provider relationship is meeting your needs.

What's diagnosis upcoding fraud? When providers or marketers submit diagnoses that are not supported by clinical evidence, either fabricated or exaggerated, to inflate RAF scores. Report to Georgia SMP.

How is Risk Adjustment related to QBP? They are sequential. Risk Adjustment determines the base capitation per member, then QBP adds a bonus for qualifying high-star plans. Both flow into total plan revenue.

How is Risk Adjustment related to MLR? Risk-adjusted capitation is part of premium revenue (the MLR denominator). Higher accurate Risk Adjustment means higher premium revenue, which means larger required clinical and QIA spending, which means more QIA investment capacity.

Does Risk Adjustment apply to standalone Part D plans? Yes. Part D has its own risk adjustment methodology (RxHCC) separate from but parallel to the MA HCC model.

Can I see my own RAF score? Not directly through standard tools. Your plan knows your RAF score but typically does not disclose it. You can infer relative risk from your diagnosis profile but cannot see the exact numeric score.

What does data collection year versus payment year mean? Diagnoses captured during calendar year T drive plan payments during calendar year T+1, with final reconciliation following CMS's annual sweep deadline.

How does Risk Adjustment affect rural Georgia plan availability? Rural Georgia areas have variable Risk Adjustment economics depending on enrollee disease burden. Combined with QBP and MLR considerations, this affects which plans enter or remain in rural markets.

What's the difference between Community Non-Disabled and Community Disabled segments? HCC model segments with separate coefficients reflecting distinct cost patterns. Community Non-Disabled covers most beneficiaries; Community Disabled covers under-65 disabled beneficiaries who entered Medicare via SSDI.

What's the Long-Term Institutional segment? HCC model segment for beneficiaries living in nursing homes long-term. Different coefficients reflect institutional care patterns.

How do ESRD beneficiaries fit in? ESRD beneficiaries trigger special Risk Adjustment treatment with different coefficients reflecting the substantial cost of dialysis and related care. A recent federal expansion allows ESRD beneficiaries to enroll in MA plans.

Should I be concerned about my plan's Risk Adjustment practices? Generally not, if your plan's documentation reflects your actual conditions. Be alert to aggressive documentation pressure (suggesting conditions you do not have) and report to Georgia SMP.

How does Risk Adjustment relate to the MA bid process? Plans bid on a standardized risk score; CMS later risk-adjusts actual payments up or down based on actual enrollee mix. This shifts risk between plans and CMS.

Where can I learn more about Risk Adjustment in Georgia? GeorgiaCares SHIP provides free education. The CMS Annual Rate Announcement details technical methodology. Medicare.gov has consumer-friendly explanations.

Phone Numbers and Resources

This guide is for educational purposes and does not constitute legal, financial, or medical advice. Consult licensed professionals and CMS resources for personalized guidance.

Find personalized help navigating Georgia Medicare Advantage and Risk Adjustment at brevy.com.