February 2, 2022

SUBJECT: Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies

<aside> 📔 Table of Contents

Details in Part D Model Changes:

2023 Part D

Interested in?

2024 Part C

2023 ESRD

NOTES:

  1. Bolded RxHCCs in the proposed RxHCC model represent disease groups that were either added or split out from current model RxHCCs.
  2. Italicized RxHCCs in the proposed RxHCC model represent disease groups that were changed from the current model.
  3. Some RxHCCs were renumbered to accommodate additional disease groups but are otherwise the same. These are not explicitly called out in the table.
  4. RxHCCs that are present in current model columns but are blank in the proposed model columns were removed from the payment model (RxHCCs 43, 68, 165, 206, 216, 241) or their conditions were moved to other payment RxHCCs (RxHCCs 96, 134, 135, 145, 397).
  5. For two disease groups (Blood and Lung), V05 RxHCCs are listed in non-chronologic order to better align content with comparable V08 RxHCCs.

SOURCE: RTI International

Table VI-8. Comparison of Current (V05) and Proposed (V08) RxHCC Risk Adjustment Models

RxHCC V05 Description RxHCC V08 Description Category
1 HIV/AIDS 1 HIV/AIDS Infections
5 Opportunistic Infections 5 Opportunistic Infections
15 Chronic Myeloid Leukemia 15 Chronic Myeloid Leukemia Neoplasm
16 Multiple Myeloma and Other Neoplastic Disorders 16 Multiple Myeloma and Other Hematologic Cancers
17 Secondary Cancers of Bone, Lung, Brain, and Other Specified Sites; Liver Cancer 17 Secondary Cancer of Bone and Kidney
18 Secondary Cancer of Lung, Liver, Brain, and Other Sites
19 Leukemias and Other Hematologic Cancers
18 Lung, Kidney, and Other Cancers 20 Lung, Kidney, and Other Cancers; Secondary Cancer of Lymph Nodes and Other Sites
21 Lymphomas and Other Hematologic Cancers
19 Breast and Other Cancers and Tumors 22 Prostate, Breast, Bladder, and Other Cancers and Tumors
30 Diabetes with Complications 30 Diabetes with Complications Diabetes
31 Diabetes without Complication 31 Diabetes without Complication
40 Specified Hereditary Metabolic/Immune Disorders 40 Alpha-1-Antitrypsin Deficiency Metabolic
41 Lysosomal Storage Disorders
42 Acromegaly and Other Endocrine and Metabolic Disorders
41 Pituitary, Adrenal Gland, and Other Endocrine and Metabolic Disorders 43 Pituitary, Adrenal Gland, and Other Endocrine and Metabolic Disorders
42 Thyroid Disorders 44 Thyroid Disorders
43 Morbid Obesity
45 Disorders of Lipoid Metabolism 47 Disorders of Lipoid Metabolism
54 Chronic Viral Hepatitis C 54 Chronic Viral Hepatitis C Liver
55 Acute or Unspecified Viral Hepatitis C
55 Chronic Viral Hepatitis, Except Hepatitis C 56 Chronic Viral Hepatitis B and Other Specified Chronic Viral Hepatitis
59 Primary Biliary Cirrhosis
65 Chronic Pancreatitis 65 Chronic Pancreatitis Gastrointestinal
66 Pancreatic Disorders and Intestinal Malabsorption, Except Pancreatitis 66 Pancreatic Disorders and Intestinal Malabsorption, Except Pancreatitis
67 Inflammatory Bowel Disease
68 Esophageal Reflux and Other Disorders of Esophagus 67 Inflammatory Bowel Disease
80 Aseptic Necrosis of Bone 80 Aseptic Necrosis of Bone Musculoskeletal
81 Psoriatic Arthropathy
82 Psoriatic Arthropathy and Systemic Sclerosis 82 Systemic Sclerosis
83 Rheumatoid Arthritis and Other Inflammatory Polyarthropathy 83 Rheumatoid Arthritis and Other Inflammatory Polyarthropathy
84 Systemic Lupus Erythematosus, Other Connective Tissue Disorders, and Inflammatory Spondylopathies 84 Systemic Lupus Erythematosus and Other Systemic Connective Tissue Disorders
87 Osteoporosis, Vertebral and Pathological Fractures 87 Osteoporosis, Vertebral and Pathological Fractures
95 Sickle Cell Anemia 95 Sickle Cell Anemia Blood
96 Myelodysplastic Syndromes and Myelofibrosis 96 Acquired Hemolytic, Aplastic, and Sideroblastic Anemias
98 Aplastic Anemia and Other Significant Blood Disorders
98 Hereditary Angioedema and Other Defects in the Complement System
97 Immune Disorders 99 Immune Disorders
100 Immune Thrombocytopenic Purpura
111 Alzheimer's Disease 111 Alzheimer's Disease Cognitive
112 Dementia, Except Alzheimer's Disease 112 Dementia, Except Alzheimer's Disease
130 Schizophrenia 130 Schizophrenia and Other Psychosis Psychiatric
131 Bipolar Disorders 131 Bipolar Disorders
132 Major Depression 132 Depression
133 Specified Anxiety, Personality, and Behavior Disorders 133 Anxiety and Other Psychiatric Disorders
134 Depression
135 Anxiety Disorders
145 Autism Developmental Disorder
146 Profound or Severe Intellectual Disability/Developmental Disorder 146 Profound or Severe Intellectual Disability/Developmental Disorder
147 Moderate Intellectual Disability/Developmental Disorder 147 Moderate Intellectual Disability/Developmental Disorder
148 Mild or Unspecified Intellectual Disability/Developmental Disorder 148 Mild or Unspecified Intellectual
Disability/Developmental Disorder
156 Myasthenia Gravis, Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease 153 Myasthenia Gravis and Other Myoneural Disorders Neurological
154 Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease
157 Spinal Cord Disorders 155 Spinal Cord Disorders
157 Chronic Inflammatory Demyelinating Polyneuritis
159 Inflammatory and Toxic Neuropathy 158 Inflammatory and Toxic Neuropathy
160 Multiple Sclerosis 159 Multiple Sclerosis
160 Huntington Disease
161 Parkinson's and Huntington's Diseases 161 Parkinson Disease
163 Intractable Epilepsy 163 Intractable Epilepsy
164 Epilepsy and Other Seizure Disorders, Except Intractable Epilepsy 164 Epilepsy and Other Seizure Disorders, Except Intractable Epilepsy
165 Convulsions
166 Migraine Headaches 166 Migraine Headaches
168 Trigeminal and Postherpetic Neuralgia 168 Trigeminal and Postherpetic Neuralgia
185 Primary Pulmonary Hypertension 183 Pulmonary Arterial Hypertension Heart
184 Pulmonary Hypertension, Except
Arterial, and Other Pulmonary Heart Disease
186 Congestive Heart Failure 186 Heart Failure
187 Hypertension 187 Hypertension
188 Coronary Artery Disease 188 Coronary Artery Disease
191 Ventricular Septal Defect and Major Congenital Heart Disorders
193 Atrial Arrhythmias 193 Atrial Arrhythmias
206 Cerebrovascular Disease, Except Hemorrhage or Aneurysm Cerebrovascular Disease
207 Spastic Hemiplegia 207 Spastic Hemiplegia
215 Venous Thromboembolism 215 Venous Thromboembolism Vascular
216 Peripheral Vascular Disease
225 Cystic Fibrosis 225 Cystic Fibrosis Lung
226 Idiopathic Pulmonary Fibrosis and Systemic Sclerosis with Lung Involvement
227 Pulmonary Fibrosis and Other Chronic Lung Disorders 227 Pulmonary Fibrosis, Except Idiopathic
228 Severe Persistent Asthma
226 Chronic Obstructive Pulmonary Disease and Asthma 229 Chronic Obstructive Pulmonary Disease, Bronchiectasis, and Other Asthma
241 Diabetic Retinopathy Eye
243 Open-Angle Glaucoma 243 Glaucoma, Open-Angle or Moderate/Severe Stage
244 Other Non-Acute Glaucoma
260 Kidney Transplant Status 260 Kidney Transplant Status Kidney
261 Dialysis Status 261 Dialysis Status, Including End Stage Renal Disease
262 Chronic Kidney Disease Stage 5 262 Chronic Kidney Disease Stage 5