Medicare Advantage Risk Rate For All Plans Except PACE

$79 / year

This dataset contains information on Medicare Advantage (MA) risk rates for all plans except Program of All-Inclusive Care for the Elderly (PACE) plans. Health plans that participate in the MA program receive monthly capitation payments for each Medicare enrollee. Key components of the Medicare Advantage rates include: 1) Revision to the risk-adjustment model to better account for fully dual eligible beneficiaries. 2) Adjustment to certain measures within the Star Ratings program for socioeconomic status. 3) Update to the blended risk scores using 75 percent of the risk score calculated using data from the Risk Adjustment Processing System (RAPS) and 25 percent of the risk score calculated using encounter data. 4) Incentives to Medicare Advantage organizations to offer plans with lower maximum out-of-pocket limits.


Medicare managed healthcare options have been available to some Medicare beneficiaries since 1982 and Medicare has paid health plans a monthly per person county rate. The monthly per person, or “per capita,” county rates were determined under the Adjusted Average Per Capita Cost (AAPCC). AAPCCs are five-year moving averages per beneficiary spending at the county level for fee-for-service Medicare. The county rates were used as the base rates for paying MA plans in 2004 and 2005. Beginning in 2006, however, the county rates were used to create benchmarks against which the plans will bid. Rates were set through competitive bid, rather than administered pricing. The benchmark for each plan was a weighted average of the county rates for the counties in the plan’s service area. The Centers for Medicare and Medicaid Services (CMS) based the Medicare payment is used for private plan on the relationship between the bid and its benchmark. Medicare payments are also based on enrolled beneficiaries’ demographics and health risk characteristics. Section 1853(a)(3) of the Social Security Act required the Secretary to develop and implement a new risk-adjustment methodology to be used to adjust the county-wide rates to reflect the expected relative health status of each enrollee. The purpose of risk adjustment is to use health status indicators to improve the accuracy of payments and establish incentives for plans to enroll and treat less healthy Medicare beneficiaries. The base payment for an enrollee is the base rate for the enrollee’s county of residence, multiplied by the enrollee’s risk measure. Coordinated care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and PACE plans are generally required to reimburse non-contracting providers at least the original Medicare rate for Medicare covered services.

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United States


John Snow Labs => Centers for Medicare and Medicaid Services

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Medicare Advantage Benchmarks, Medicare Advantage Risk Rates, Medicare Advantage Rates, Adjusted Average Per Capita Cost Methodology, Medicare Fees, Medicare Risk Scores, Fee-for-Service Medicare Costs, Medicare Payments, Advantage Payment Rates

Other Titles

Medicare Advantage Risk Rates For All Plans Except Program of All Inclusive Care for the Elderly, Medicare Risk Adjustments All Plans Except PACE, Medicare Advantage Risk Adjustments

Name Description Type Constraints
Current_YearThe year to which the risk score is calculateddate-
Following_YearThe coming year, to which the calculated values are provideddate-
County_FIPS_CodeThe 5 digits county Federal Information Processing Standard (FIPS) codeinteger-
State_AbbreviationName of state for which risk score is calculatedstring-
CountyCounty Name for which risk score is calculatedstring-
FFS_Rate_Current_YearThe Medicare fee for service (FFS) rate; rebasing of Fee-for-Service (FFS) Counties CMS is necessary to rebase FFS county rates at least every three years, and has done so each year since 2012; rebasing is designed to update the county base rates to ensure they reflect spending model across the country for Original Medicarenumberlevel : Ratio
IME_Phase_Out_Dollar_Amount_Current_YearPhase-out of the incremental payments for Indirect Medical Education (IME); IME Phase-out represents phase-out of the incremental payments for IME resulted from including incremental amounts in both the health plans’ premium payments from CMS and the payments made directly to such hospitals by CMSnumber-
Pre_ACA_Rate_Excludes_Phased_Out_IME_Current_YearPre Affordable Care Act Rate Excluding Phased out Indirect Medical Educationnumberlevel : Ratio
Pre_ACA_Rate_Includes_Phased_Out_IME_Current_YearPre Affordable Care Act Rate Including Phased out Indirect Medical Educationnumberlevel : Ratio
Rate_Category_Current_YearSpecifies whether the Medicare rate category is minimum update or fee-for-servicestring-
Minimum_Update_Rate_Following_YearThe Minimum Update Rate for the coming year is the current year Pre-ACA Rate including all IME x coming year Adjusted Growth Factor x Risk Score Model Adjustment Factornumberlevel : Ratio
Risk_Score_Model_Adjustment_FactorsRisk Score adjustment factor; a risk score which indicates how costly the enrollee is expected to be relative to the national average beneficiary; the purpose of the risk scores is to adjust MA payments so that they accurately reflect how much each MA enrollee would be expected to costnumberlevel : Ratio
Graduate_Medical_Education_Factor_Following_YearGraduate medical education expense factornumberlevel : Ratio
DOD_Adjustment_Factor_Following_YearAdjustment for the Department of Defense (DOD) eligible beneficiariesnumberlevel : Ratio
Veterans_Affairs_Adjustment_Factor_Following_YearAdjustment for veteransnumberlevel : Ratio
DOD_Veterans_Combined_Adjstment_Factor_Following_YearCombined adjustment the Department of Defense (DOD) eligible beneficiaries and veteransnumberlevel : Ratio
Average_Geographic_Adjustment_Factor_Following_YearAdjustment on geographic regions; the Average Geographic Adjustment (AGA) re-pricing adjusts individual county rates to reflect each county’s historical 5-year rolling average FFS cost relative to the FFS national averagenumberlevel : Ratio
FFS_Including_All_IME_Following_YearRebasing of FFS Counties CMS is necessary to rebase FFS county rates at least every three years, and has done so each year since 2012; FFS Rate including all IME = FFS United States Per Capita Costs (USPCC) x AGA x (1 - GME factor) x (DOD Adjustment Factor + VA Adjustment factor - 1) x Credibility Factornumberlevel : Ratio
Is_Credibility_AdjustedCredibility adjusted or notboolean-
Credibility_FactorsCredibility factornumberlevel : Ratio
IME_Factor_Following_YearIndirect medical education factornumberlevel : Ratio
IME_Phase_Out_Factor_Following_YearThe IME phase out factornumberlevel : Ratio
IME_Phase_Out_Dollar_Amount_Following_YearThe IME Phase out amountnumber-
FFS_Rate_Excluding_Phase_Out_IME_Following_YearFFS rate excluding phase out IMEnumberlevel : Ratio
Pre_Affordable_Care_Act_Rate_Excludes_Phased_Out_IME_Following_YearPre affordable care act rate excluding phase out IMEnumberlevel : Ratio
Pre_Affordable_Care_Act_Rate_Category_Following_YearPre affordable care act rate categorystring-
Transition_YearsNumber of yearsnumberlevel : Ratio
Quartile_Percent_FactorQuartile factor in percentnumberlevel : Ratio
Is_Urban_Floor_In_2004Urban floor or notboolean-
MA_Penetration_Rate_Dec_2009Medicare advantage penetrationnumberlevel : Ratio
Is_MA_Penetration_Is_At_Least_25_PercentMedicare advantage penetration is at least 25%boolean-
FFS_Rate_Including_Graduate_Medical_Education_Following_YearThe FFS rate including GMEnumberlevel : Ratio
Is_FFS_Rate_Less_Than_FFS_US_Per_Capita_Cost_Following_YearFFS rate is less than FFS US per capita costboolean-
Is_Qualifying_CountyCounty characterboolean-
Is_All_Bonus_Rates_CappedBonus rates capped; Quality Bonus represents the impact of changes in bonus money associated with Star Quality ratings; for 2015, this also included the impact of the sunset of the Star demonstration program from CMSboolean-
Is_Five_Percent_Bonus_Rate_CappedBonus rate capped 5%boolean-
Is_Percent_Rate_Bonus_CappedBonus rate capped 3.5%boolean-
Is_Zero_Percent_Bonus_Rate_CappedBonus rate 0% cappedboolean-
Five_Percent_Bonus_Rate_Following_Year5% bonus ratenumberlevel : Ratio
Percent_Bonus_Rate_Following_Year3.5% bonus ratenumberlevel : Ratio
Zero_Percent_Bonus_Rate_Following_Year0% bonus ratenumberlevel : Ratio
2016201765190GUToto414.592.49469.15471.64Minimum update486.171.000.00181.00001.010.53435.16false1.000.00621.002.69432.47483.48Minimum update61.15falsefalsetruefalsetruetruetruetrue483.48483.48483.48
2018201965190GUToto437.062.84495.63498.47Minimum update528.031.000.00181.000.52460.05false1.000.00691.003.18456.87524.85Minimum update61.15falsefalse460.88truefalsetruetruetruetrue524.85524.85524.85
2016201765130GUOrdot414.592.49469.91472.40Minimum update486.951.000.00181.00001.010.53435.16false1.000.00621.002.69432.47484.26Minimum update61.15falsefalsetruefalsetruetruetruetrue484.26484.26484.26
2016201737290OKHarper775.683.71784.44788.15Minimum update812.431.000.00141.00001.010.94796.31true1.020.00481.003.84792.47808.59Minimum update21.00falsefalsetruefalsefalsetruetruefalse808.59808.59792.47
2016201765090GUMaite414.592.49496.02498.51Minimum update513.861.000.00181.00001.010.53435.16false1.000.00621.002.69432.47511.17Minimum update61.15falsefalsetruefalsefalsetruetruefalse511.17511.17497.34
2018201906550COSan Juan782.374.07828.91832.98Minimum update882.381.000.00331.010.84855.69true1.130.00791.006.72848.97875.66Minimum update61.08falsefalse858.49truefalsetruetruetruetrue875.66875.66875.66
2018201937290OKHarper826.683.97829.01832.98Minimum update882.381.000.00131.010.99899.53true1.020.00501.004.54894.99894.99Fee-for-service21.00falsefalse900.74falsefalsetruetruetruetrue894.99894.99894.99
2018201965130GUOrdot437.062.84496.43499.27Minimum update528.881.000.00181.000.52460.05false1.000.00691.003.18456.87525.70Minimum update61.15falsefalse460.88truefalsefalsetruetruefalse525.70525.70525.40
2016201752250WIIron701.634.64783.51788.15Minimum update812.431.000.00291.00001.030.89745.53true1.000.00731.005.46740.07806.97Minimum update21.15false0.3472truetruefalsetruetruetruetrue806.97806.97806.97
2016201765030GUAgat414.592.49519.49521.98Minimum update538.061.000.00181.00001.010.53435.16false1.000.00621.002.69432.47535.37Minimum update61.15falsefalsetruefalsefalsefalsefalsefalse518.96512.48497.34