RISE National

Changes to Risk Adjustment and RADV

The proposed 2026 Medicare Advantage and Part D Advance Notice released on January 10, included proposed changes to the risk adjustment model. CMS may complete its phase-in of the 2024 CMS-HCC risk adjustment model (v28) in 2026 and may begin calibrating the model using encounter data as early as 2027. Further, we continue to witness how CMS is operationalizing the RADV rule finalized in 2023, both in the methodology used for plan selection and number of plans audited. 

Evolution of Quality and Member Care

Programmatic changes to MA Stars and quality reporting, such as the use of the health equity index and the inclusion of the universal foundation measure set, mean plans continue to navigate uncertainty. Further, discussions around prior authorization and the use of AI in defining care will further change the landscape of member care. 

Navigating the Change in Administration

A change in administration means evaluating policies established in the prior administration that are likely to be removed as well as identifying new policy directions the administration will take. Much is left to be discussed around topics such as the emphasis on health-related social needs and how telehealth and care provided at home get incorporated into risk and quality programs and plan operations.