Risk Adjustment
Risk Adjustment Factor (RAF) Score(RAF)
Per-member coefficient that summarizes expected cost relative to an average Medicare Advantage enrollee.
Definition
The Risk Adjustment Factor (RAF) score is a per-member coefficient produced by the CMS Hierarchical Condition Category model. A patient's RAF is built from demographic factors (age, sex, Medicaid dual-eligible status, originally-disabled flag) plus the sum of the coefficients of all HCCs documented during the prior calendar year.
An average MA member has a RAF of 1.0 by construction; sicker members have higher RAFs and trigger higher capitation. CMS recalibrates the coefficients annually as part of the Rate Announcement.
RAF flows directly into payments: monthly capitation is approximately RAF x base rate, and is paid prospectively each month then trued up after CMS receives EDS / RAPS submissions for the year.
When to use
- •You need to estimate dollar impact of a coding decision, not just clinical accuracy.
- •You're modeling member panels and want to project annual revenue per cohort.
- •You're explaining to a clinical leader why specificity upgrades matter financially.
Try it in AutoICD API
Get RAF impact in audit response
curl -X POST https://autoicdapi.com/v1/audit \
-H "Authorization: Bearer $AUTOICD_API_KEY" \
-H "Content-Type: application/json" \
-d '{
"text": "Chronic systolic heart failure, NYHA III. CKD stage 3b. T2DM with peripheral neuropathy.",
"submitted_codes": ["E11.9", "I50.9"],
"capabilities": ["hcc"]
}'
# response.totals.raf_upside lists the dollar value
# of every missed HCC, summed per year.Language: bash. View full API docs · Get an API key.