Page 65

65

CMS-HCC Risk Adjustment Model for PACE Organizations for CY 2026 Comment: All commenters who commented on the risk adjustment model proposal for PACE organizations supported the phase out of the 2017 CMS-HCC model and phasing in of the model currently used for MA organizations (the 2024 CMS-HCC model). A couple of commenters were pleased that dementia would be recognized for PACE as CMS migrates to the 2024 CMS- HCC model. Response: We thank the commenters for their support. For CY 2026, CMS will blend 10 percent of the risk score calculated using the 2024 CMS-HCC risk adjustment model with 90 percent of the risk score calculated using the 2017 CMS-HCC risk adjustment model. Section K. ESRD Risk Adjustment Models for CY 2026 For Non-PACE Organizations Comment: One commenter supported the continued use of the 2023 CMS-HCC ESRD models for CY 2026. The commenter also expressed concern that the model does not fully account for the higher costs of ESRD beneficiaries and requested that CMS take this into consideration for future updates, as well as providing at least 60 days to comment. Response: We thank the commenter for their support. Payments for enrollees in dialysis or transplant status are calculated using the appropriate ESRD risk scores and a separate state-level ratebook; this separate ratebook comprises much higher rates than the county ratebook used in bidding. While the county ratebook is used for functioning graft enrollees, ESRD functioning graft risk scores, which are based on the non-ESRD model, are higher than risk scores for non- ESRD enrollees. Please see the CY 2023 Advance Notice and Rate Announcement for more information on the risk scores for dialysis and functioning graft enrollees.10 For CY 2026, we will continue to calculate risk scores for payment of beneficiaries with ESRD in MA plans and certain demonstrations using the 2023 CMS-HCC ESRD risk adjustment models as proposed in the CY 2026 Advance Notice. For PACE Organizations CMS did not receive comments on the CMS-HCC ESRD risk adjustment models for PACE organizations for CY 2026. CMS will calculate blended risk scores for PACE participants with ESRD using a sum of 90 percent of the risk score calculated with the 2019 ESRD CMS-HCC models and 10 percent of the risk score calculated with the 2023 ESRD CMS-HCC models as proposed in the CY 2026 Advance Notice.

10 Refer to CMS’ CY 2023 Advance Notice and CY 2023 Rate Announcement.