Plain-language explainers on Part D risk adjustment, the IRA redesign, and prior auth rules — every claim tied to CMS sources.
Explore effective ACO Part D risk adjustment strategies to optimize Medicare plans and improve patient outcomes.
Learn about chronic condition documentation in Medicare and its impact on risk adjustment and reimbursement. Essential insights for MA-PD plans and ACOs.
Explore the significant changes to the CMS HCC model in 2024 and their implications for Medicare plans and providers.
Explore the CMS RxHCC model documentation for effective Medicare Part D risk adjustment and utilization management strategies.
The five finalized CY2027 RxHCC model changes — MA-PD vs PDP segments, 2023/2024 recalibration, audio-only and unlinked chart review exclusions, and normalization factors 1.109 / 1.005 — with direct CMS citations.
Learn how direct subsidy calculations impact Medicare Part D plans and their funding. Explore the CMS methodologies and implications for your organization.
Explore the importance of health plan provider alignment in risk adjustment for Medicare Part D and its impact on plan performance.
Learn how the CMS HCC model works for Medicare Part D risk adjustment and its impact on MA-PD plans, PDPs, and more.
How ICD-10-CM diagnoses map into the 84 RxHCC categories for CY2027, worked examples, and links to the official CMS mapping files and model software.
Explore the significance of the institutional status RxHCC coefficient in Medicare Part D risk adjustment and its impact on healthcare organizations.
Explore the implications of the IRA Part D redesign plan liability on MA-PD plans, PDPs, and other healthcare organizations.
Learn about long term institutionalized Part D scoring and its implications for Medicare plans and providers.
Learn how to optimize MA-PD risk scores while ensuring compliance with CMS regulations.
Explore effective MAPD risk adjustment strategies to optimize your Medicare plan's performance and compliance.
Explore how Medicare drug price negotiation affects Part D plans and beneficiaries, including insights from the Inflation Reduction Act.
Learn about the $2000 out-of-pocket cap in Medicare Part D, its implications, and how it affects plans and beneficiaries.
Explore the differences between Medicare Part D reinsurance and risk sharing in this comprehensive guide for MA-PD plans and PDPs.
Explore the intricacies of Part D bid risk adjustment and its implications for Medicare plans.
Explore the implications of the Part D catastrophic phase and the 60% plan share for MA-PD plans, PDPs, and other healthcare organizations.
Explore the implications of Part D frailty adjustment in Medicare risk adjustment models and its impact on MA-PD plans and PDPs.
Explore how low income subsidy risk adjustment impacts Medicare Part D plans and beneficiaries.
Explore the Part D Manufacturer Discount Program and its impact on Medicare beneficiaries and plans. Learn how it affects drug pricing and access.
Explore the intricacies of Part D PDE reporting and its impact on risk adjustment in Medicare. Learn how it affects your organization.
Explore the key data sources for Medicare Part D risk adjustment and their implications for MA-PD plans, PDPs, and more.
Explore a detailed example of Part D risk score calculation and its implications for MA-PD plans and PDPs.
Explore the 2026 Part D risk sharing thresholds and their implications for MA-PD plans, PDPs, and ACOs in the evolving Medicare landscape.
Explore the implications of drug risk for Part D sponsors under the CMS RxHCC model.
The 72-hour clock is the Part D standard drug coverage determination deadline (42 CFR 423.568); expedited is 24 hours (423.570). Distinct from CMS-0057-F's medical PA timeframes.
CMS-0057-F sets 72-hour urgent and 7-calendar-day standard prior authorization decisions for medical items and services — and explicitly excludes drugs. Part D drug coverage determinations follow a separate 72/24-hour regime.
Explore the role of prospective risk adjustment in Medicare Part D and its implications for MA-PD plans, PDPs, and more.
Learn how to improve provider documentation for effective RxHCC risk adjustment in Medicare.
Essential steps for MA-PD plans and PDPs to prepare for RADV audits in Medicare Part D.
Learn about RADV extrapolation in Medicare Part D, its implications, and how it affects risk adjustment and utilization management.
Explore the significance of retrospective chart reviews in Medicare Part D risk adjustment and their impact on healthcare outcomes.
Explore the differences between retrospective and prospective RxHCC models in Medicare Part D risk adjustment.
Ensure your Medicare plan is prepared for RxHCC audits with our comprehensive guide on audit readiness strategies and best practices.
Explore RxHCC coding guidelines to optimize risk adjustment and compliance in Medicare Part D plans.
Learn about the RxHCC coding intensity adjustment and its impact on Medicare Part D plans.
Explore the 2025 RxHCC coefficients and their implications for Medicare plans. Learn how to navigate the changes effectively.
Explore the RxHCC coefficients for 2026 and their implications for Medicare plans and providers.
Complete CY2027 RxHCC relative factors for continuing enrollees, with MA-PD and PDP segments side by side, 2026 values, and year-over-year change. From the CY2027 Rate Announcement, Tables VIII-1 and VIII-5.
All 84 RxHCC condition categories in the CY2027 Part D risk adjustment model, from the Rate Announcement continuing-enrollee tables, with links to coefficients and hierarchies.
Learn about RxHCC data validation audits and their importance for Medicare plans in risk adjustment and compliance.
Explore the RxHCC disabled status segment and its implications for Medicare plans and risk adjustment strategies.
Explore the essential RxHCC documentation requirements for effective Medicare Part D risk adjustment.
Learn about RxHCC encounter data submission for Medicare plans and how it impacts risk adjustment.
Explore how RxHCC impacts ACOs and enhances risk adjustment in Medicare Part D.
Explore how RxHCC impacts small PBMs and enhances risk adjustment in Medicare Part D.
Explore common questions about RxHCC, Medicare Part D risk adjustment, and how it impacts healthcare plans.
How RxHCC disease hierarchies drop lower-severity categories, with the complete CY2027 hierarchy list from Rate Announcement Table VIII-13 and a worked payment example.
Concise summary of the finalized CY2027 Part D risk adjustment model — segments, calibration years, exclusions, normalization factors — with page-level citations to the Rate Announcement.
CY2027 is the first year RxHCC disease coefficients are segmented by plan type. How the five continuing-enrollee segments work in each population and where the values diverge.
CY2027 RxHCC normalization factors are 1.109 for MA-PD plans and 1.005 for PDPs (1.237 for the PACE 2018/2019 calibration). What normalization does, the methodology, and the payment math.
Learn about RxHCC overpayment recovery processes by CMS and how it impacts Medicare plans.
Learn how RxHCC point of care capture improves Medicare Part D risk adjustment and enhances patient care.
Understand the differences between the RxHCC (Part D drug risk) and CMS-HCC (Part C medical risk) models, and why plans must manage both.
Explore effective strategies for small PBMs to ensure risk adjustment compliance in Medicare Part D.
Primary public sources that substantiate the RxHCC, Part D risk adjustment, and prior authorization claims made on rxhcc.com.
Learn how RXHCC scoring impacts Special Needs Plans and their performance in Medicare Part D.
Learn about suspect condition identification in Medicare Part D and its impact on risk adjustment and utilization management.
Explore the benefits of UM automation in Medicare Advantage plans and how it can enhance efficiency and compliance.
Explore how value-based care impacts pharmacy risk in Medicare Part D.
Learn what RxHCC is and how it impacts Medicare Part D risk adjustment and utilization management for healthcare organizations.
