New Enrollee, New Plan Year: Which Diagnoses Move Which Payment
Mr. Okafor turns 65 in November 2024 and enrolls in a Medicare Advantage plan effective January 1, 2025. He has never been in Medicare; through 2024 he held a marketplace silver plan. His 2025 records show COPD with acute exacerbation documented by his pulmonologist at a February office visit, type 2 diabetes with diabetic retinopathy documented in an April hospital discharge summary after a right below-knee amputation, and a March physical therapy note whose past-medical-history section lists 'diabetes with retinopathy.' A 2023 rheumatology note documenting rheumatoid arthritis on methotrexate was also found in the chart. In June the plan's risk adjustment analyst proposes submitting all four items to raise the 2025 risk score, which currently sits at the new-enrollee level. The plan also operates an ACA individual-market product and asks whether the same submission logic applies there.
1. Explain what the 2025 risk score is built from and which of the four items can affect it.
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How the 2025 score is built. CMS-HCC payment is prospective: the 2025 payment year is scored from diagnoses with 2024 dates of service. Mr. Okafor had no Medicare Advantage coverage in 2024, so there is no diagnosis history to score - he falls under the new-enrollee model, which uses age, sex, and (where applicable) institutional status. His 2025 conditions do not change his 2025 payment.
What the 2025 diagnoses actually do. They are submitted as 2025 encounter data and become the inputs for his 2026 payment year, subject to the same documentation and encounter-source rules. So the analyst's premise is wrong on timing, not just on sources.
Item by item:
- February pulmonology office visit - COPD with acute exacerbation. A face-to-face encounter with an acceptable provider specialty; usable for the 2026 payment year.
- April discharge summary - diabetes with retinopathy and amputation status. Inpatient documentation by an acceptable provider; usable for 2026, and the retinopathy and amputation each carry meaningful weight.
- March physical therapy note. A history-section mention by a non-physician/non-NPP clinician is not a diagnosis made at a qualifying encounter. Do not submit.
- 2023 rheumatology note. Outside the 2024 data year for 2025 payment and outside 2025 for 2026. Rheumatoid arthritis must be re-documented at a qualifying 2025 encounter to count for 2026.
The lesson: HCC capture has a calendar, not just a code list.
2. The plan asks whether the same submission logic applies to its ACA individual-market product. What differences matter?
Read the worked answer
No - the workflow looks similar, the rules do not transfer.
- Different model. The ACA market uses the HHS-operated risk adjustment program with HHS-HCC categories, its own coefficients, and its own hierarchies. A condition that is HCC-bearing under CMS-HCC may map differently, or not at all, under HHS-HCC. Never port a CMS-HCC capture list into an ACA file.
- Different population and plan variables. HHS risk adjustment is computed at the enrollee level using age, sex, rating area, metal level, and enrollment duration in addition to diagnoses; a member enrolled for four months is scored differently from one enrolled all year.
- Different data flow. ACA risk adjustment runs on enrollee-level claims submitted by issuers through the EDGE server, and the program is run by CMS on behalf of the states rather than by a plan's own payment model. Errors surface through HHS-RADV, not CMS RADV.
- Different market scope. It applies to the non-grandfathered individual and small-group markets; large-group and self-funded business is outside it entirely.
- Same underlying discipline. In both programs, a diagnosis must be documented at a qualifying encounter by an acceptable provider and be supported by the record. The documentation standard is shared; the math is not.
A single chart review can serve both products, but the code-to-category crosswalk and the payment timing must be handled separately.