Most healthcare professionals are familiar with Hierarchical Condition Categories (HCCs) and their important role in the reimbursement process. However, it’s not always easy to understand the differences between the HCCs used by the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS).
Keep reading to brush up on the key differences between these two methodologies.
Who uses CMS-HCC or HHS-HCC risk adjustment models?
CMS-HCC scores determine Medicare and Medicare Advantage payments. HHS-HCC scores use a different set of HCCs to determine risk-adjustment reimbursement rates for those with insurance plans on the Affordable Care Act (ACA) marketplace.
What are the similarities between CMS-HCC and HSS-HCC models?
Both sets of HCCs are used to provide risk-adjusted payments for patients with more complex care needs, aligning plan payments with expected costs.
INSIGHT BRIEF
A proactive approach to HCC management for better risk-adjusted reimbursement
What are the key differences between CMS-HCC (Medicare) and HHS-HCC (ACA) models?
Population and markets: CMS focuses on Medicare and Medicare Advantage patients, primarily those over 65 who have disabilities. HHS spans all ages in ACA markets.
Timing: CMS is prospective, HSS is concurrent.
Overall, the CMS-HCC model is integrated into many electronic health records (EHRs), whereas many health systems aren’t familiar with the HHS-HCC model.
What’s unique to the HHS-HCC model (pediatrics, maternity, RxCs)?
HHS includes infant, child, and maternity categories and adds RxCs (pharmacy categories) to its risk score. CMS does not score pediatrics or obstetrics in the CMS-HCC payment model.
How are CMS-HCC and HSS-HCC risk scores calculated?
CMS-HCC uses the current year’s diagnoses to determine next year’s reimbursement rates. HHS-HCC uses the current year’s data for current-year transfers between plans.
How often are HCC models updated?
CMS (MA) issues its Final Rate Announcement annually (typically early April). HHS Payment Notice is finalized annually, but timing varies (e.g., Apr 15, 2024 for 2025; Jan 15, 2025 for 2026).
