2026 Risk Adjustment Halftime Report: Trends, Threats, and Opportunities

The First Half in Review

The first half of 2026 has tested every assumption Medicare Advantage plans held about their risk adjustment readiness. This is the first payment year where CMS-HCC V28 stands alone, with no V24 blending to cushion its impact. For many organizations, the gap between what they expected and what they experienced has been significant.

MA enrollment continues to grow, surpassing 35.4 million beneficiaries nationally. CMS annual payments to MA plans exceed $450 billion, making risk adjustment accuracy more consequential than ever. The combination of V28 implementation, intensified RADV enforcement, and accelerating technology adoption has created a risk adjustment environment that rewards preparation and punishes complacency.

• V28 Revenue Impact: Across the industry, RAF scores have declined 3-15% compared to V24-equivalent scores for identical patient populations. Plans that completed V28 readiness during the transition period report declines at the lower end of this range; those that deferred preparation are experiencing the steeper drops.
• RADV Enforcement Acceleration: CMS expanded RADV audit scope in the first half, auditing more contracts with larger sample sizes. OIG published two major reports identifying risk adjustment coding as a priority enforcement area.
• Technology Inflection Point: API-driven risk adjustment tools crossed a critical adoption threshold, with more than half of large MA plans now using real-time scoring APIs in at least one operational workflow.
• Star Ratings Convergence: The intersection of Star ratings and risk adjustment strategy became more explicit as plans recognized that the same documentation and coding improvements that drive RAF accuracy also improve quality measure performance.

V28 Impact Assessment

Now that plans have six months of pure V28 data, the actual impact of the model change is coming into focus. The picture is more nuanced than the single 3.12% average decline that CMS projected.

• Constraining Impact: The constraining mechanism, which assigns identical coefficients to related HCCs within the same disease family, has produced the largest RAF score reductions for plans with populations concentrated in severe chronic disease manifestations. Plans with high diabetes severity, complex cardiovascular conditions, and advanced renal disease have seen the steepest declines because the value premium for severity has been eliminated.
• Code Mapping Losses: The reduction from 9,797 to 7,770 mapped ICD-10 codes continues to surprise plans that did not conduct code-level impact analyses before 2026. Conditions that quietly generated HCC value under V24 have silently dropped off RAF scores, and many plans have not yet identified all the specific codes they lost.
• New Capture Gains: Plans that proactively targeted the 268 newly mapped codes and new HCC categories in V28 are partially offsetting constraining and code loss impacts. Behavioral health conditions, pressure ulcer staging, and cancer site specificity represent the largest new capture opportunities.
• Demographic Recalibration: V28's recalibrated demographic coefficients have shifted the baseline values for certain age-sex-eligibility combinations, creating unexpected gains for some population segments and additional losses for others. Plans with younger, community-dwelling populations have generally fared better than those with older, dual-eligible populations.
• Interaction Factor Changes: Modified disease interaction terms have altered the incremental value of certain condition combinations. Plans are still discovering which condition pairs gained or lost interaction value under V28.

The key finding: V28 impact varies dramatically by plan based on population disease mix, coding maturity, and operational readiness. Industry averages are misleading. Every plan needs its own V28 impact assessment based on its specific population and operational data.

RADV and Compliance Trends

The compliance landscape has shifted materially in the first half of 2026, with CMS and OIG both increasing pressure on risk adjustment accuracy and documentation support.

• Expanded Audit Scope: CMS has increased the number of contracts selected for RADV audit and expanded sample sizes within each audit. The probability that any given MA contract will face a RADV audit has increased, making compliance readiness a universal concern rather than a selective risk.
• Extrapolation Enforcement: CMS has continued to refine its RADV extrapolation methodology, making individual audit findings more financially impactful. A single unsupported HCC in an audit sample can generate extrapolated repayment demands that dwarf the individual diagnosis value.
• OIG Focus Areas: OIG reports published in the first half identified specific disease categories with elevated rates of unsupported diagnoses, including diabetes complications, cardiovascular conditions, and certain cancer types. Plans should treat these reports as a preview of future enforcement priorities.
• Chart-Level Documentation Standards: CMS has provided additional guidance on what constitutes adequate documentation support for HCCs, raising the bar for conditions that previously occupied a gray area. Organizations must update their documentation standards to reflect the latest guidance.
• Proactive Compliance Adoption: The first half has seen a notable increase in plans investing in pre-submission validation and continuous compliance monitoring, driven by the combination of increased enforcement and the availability of automated scrubbing tools. Plans that invested in proactive compliance report significantly lower anxiety about RADV exposure.

Technology and Automation Adoption

2026 marks a turning point in risk adjustment technology adoption. The tools that were considered advanced capabilities two years ago are rapidly becoming baseline requirements for competitive operations.

• API-Driven Risk Scoring: More than half of large MA plans (100,000+ members) now use API-based risk scoring for at least one operational workflow, up from approximately 30% in 2024. The shift from batch-oriented to real-time scoring is accelerating as plans discover the revenue and efficiency benefits of immediate RAF score availability.
• Automated Pre-Submission Scrubbing: Investment in automated RADV scrubbing tools has grown sharply, driven by expanded enforcement. Plans are moving from sampling-based compliance review to comprehensive automated validation of every submitted HCC.
• Integrated Analytics Platforms: The trend toward unified platforms that connect coding, scoring, compliance, and reporting into a single workflow is displacing the point-solution approach where each function operates on separate technology. Integration eliminates data handoff errors and reduces cycle time.
• Predictive Gap Analytics: Advanced analytics that predict which members have unrecaptured conditions based on clinical patterns, pharmacy data, and utilization history are becoming standard practice. These tools enable prospective interventions rather than retrospective chart review.
• Provider-Facing Technology: Plans are increasingly deploying provider-facing tools that deliver risk gap information directly into clinical workflows, enabling documentation improvement at the point of care rather than through after-the-fact education.

The technology adoption gap between early adopters and laggards is widening. Plans that have not invested in modern risk adjustment technology are falling further behind operationally, financially, and competitively.

What Top Performers Are Doing Differently

Analysis of plans in the top performance quartile reveals five distinguishing practices that separate leaders from the rest of the industry.

• V28 Readiness Was Complete Before January 2026: Top performers did not treat V28 as a 2026 problem. They completed impact analyses, retrained staff, updated systems, and adjusted strategies during the 2024-2025 blended transition years. When 100% V28 arrived, they were operating from established baselines rather than scrambling to adapt.
• Prospective and Retrospective Programs Run in Parallel: Leading plans operate both prospective risk capture (identifying gaps before patient encounters) and retrospective capture (reviewing past encounters for missed conditions) simultaneously. This dual approach maximizes capture by addressing gaps through multiple channels.
• Continuous Compliance Monitoring: Rather than annual or quarterly compliance reviews, top performers maintain continuous automated monitoring that validates every submission in real time. This approach catches issues when correction is still possible, rather than discovering them during audits. V28-specific validation rules are critical to this capability.
• Integrated Risk and Quality Strategy: The best-performing plans have broken down the organizational silos between risk adjustment and quality/Star ratings teams. They recognize that accurate clinical documentation drives both revenue and quality measure performance, and they deploy unified provider engagement programs.
• Data-Driven Resource Allocation: Top performers use analytics to allocate risk adjustment resources where they will generate the highest return: specific providers with the largest capture gaps, specific disease families with the most recoverable revenue, and specific members with the highest probability of unrecaptured conditions.

The unifying theme among top performers is not a single technology or process but a management philosophy that treats risk adjustment as a continuous, data-driven operational discipline rather than an annual compliance exercise.

Priorities for the Second Half

With six months remaining in the 2026 payment year, risk adjustment teams must focus on the highest-impact activities that can still influence this year's outcomes while positioning for 2027.

• Close V28-Specific Gaps: Using first-half data, identify the specific HCC categories where your plan underperformed V28 projections. Prioritize provider outreach and chart review for the disease families with the largest recoverable revenue. Every gap closed before year-end contributes to 2026 RAF scores.
• Maximize Annual Wellness Visits: The annual wellness visit is the single most productive encounter for HCC recapture. Plans should push to complete outstanding wellness visits before Q4 scheduling becomes constrained. Target members with the most suspected unrecaptured conditions first.
• Finalize Encounter Submissions: Review encounter submission pipelines to ensure all first-half encounters have been submitted and accepted by CMS. Identify and resolve rejected encounters before year-end deadlines. Submission completeness directly determines RAF accuracy.
• Conduct RADV Readiness Assessment: With expanded RADV audit scope, every plan should conduct a self-assessment of audit readiness. Review a sample of submitted HCCs for documentation support, identify high-risk categories, and remediate gaps while correction is still possible.
• Begin 2027 Bid Preparation: Accurate 2026 V28 data is essential for 2027 bid development. Start building 2027 revenue projections based on actual V28 performance, not adjusted V24 estimates. The future of risk adjustment will continue evolving, and bid strategy must reflect current-model realities.
• Evaluate Technology Gaps: If the first half revealed operational bottlenecks that manual processes cannot resolve, the second half is the time to evaluate and procure technology solutions for 2027 deployment. Plans that begin technology procurement in Q4 can have new capabilities operational by Q2 2027.

The second half of 2026 is not the time for strategic experiments or major operational changes. It is the time for focused execution on the highest-impact activities, using the data from the first half to target effort precisely where it will generate the greatest return.