What Is a RAF Score? The Complete 2026 Guide for Payers & Providers

What Is a RAF Score

Understanding what is a RAF score is essential for any organization in Medicare Advantage. A Risk Adjustment Factor (RAF) score is a numeric value assigned to each Medicare beneficiary that predicts their expected healthcare costs relative to the average Traditional Medicare enrollee. CMS uses RAF scores to adjust capitation payments made to Medicare Advantage plans.

The baseline is 1.0 — representing the average cost of a Traditional Medicare beneficiary.

• Above 1.0: The member is expected to cost more than average due to greater clinical complexity
• Below 1.0: The member is expected to cost less than average
• 2.0: Roughly twice the expected cost of an average beneficiary

RAF scores are calculated using the CMS Hierarchical Condition Category (CMS-HCC) model, which maps ICD-10 diagnosis codes from claims and encounters to condition categories that carry predefined risk weights.

How RAF Scores Are Calculated

The RAF score calculation follows a structured process under the CMS-HCC model:

• Demographic Baseline: Each member starts with a base value determined by age, sex, Medicaid dual-eligibility status, and community vs. institutional setting. A 72-year-old male with dual eligibility receives a demographic baseline of approximately 0.626.
• ICD-10 to HCC Mapping: Diagnosis codes are mapped to Hierarchical Condition Categories. Under V28, approximately 7,770 ICD-10 codes map to 115 HCCs organized into 26 disease families.
• Hierarchy Application: Within each disease family, only the most severe condition counts — preventing double-counting of related diagnoses.
• Coefficient Assignment: Each qualifying HCC carries a CMS-published risk coefficient reflecting its predicted cost impact.
• Disease Interactions: Certain condition combinations trigger additional risk weights. Diabetes combined with congestive heart failure, for example, generates an interaction factor beyond the individual HCC values.
• Final Score: RAF Score = Demographic Value + Sum of HCC Coefficients + Sum of Interaction Factors, divided by a normalization factor for budget neutrality.

A detailed walkthrough with worked examples is available in the guide to calculating RAF scores.

What Changed in 2026: CMS-HCC V28

2026 marks a critical milestone: CMS-HCC V28 is now the sole model for RAF score calculation. The blended transition period (67/33 in 2024, 33/67 in 2025) is over.

• HCC Count: Increased from 86 (V24) to 115 (V28), organized into 26 disease families
• ICD-10 Codes Mapped: Decreased from 9,797 (V24) to 7,770 (V28) — 2,294 codes removed, 268 new codes added
• Model Basis: V28 was rebuilt natively on ICD-10 classification, replacing V24's ICD-9 legacy roots
• Constraining: The most significant change — related HCCs within the same disease family now carry identical coefficients regardless of severity. All diabetes HCCs (except pancreas transplant) share the same weight of approximately 0.166, a fundamental departure from V24 where more severe conditions earned higher coefficients.

CMS projected a 3.12% reduction in MA risk scores under V28. Early industry reports show RAF score declines of 5–30% for plans maintaining identical patient populations — driven primarily by constraining and the reduction in mapped diagnosis codes.

RAF Score Ranges

There is no universally "good" or "bad" RAF score. What matters is accuracy — whether the score reflects the true clinical complexity of the patient.

• 0.2–0.5: Healthy, younger enrollees with minimal chronic conditions
• 0.5–1.0: Mild to moderate chronic conditions
• 1.0–2.0: Multiple chronic conditions, moderate complexity
• 2.0–4.0: Complex patients with significant comorbidities
• 4.0+: Extremely complex, often institutionalized patients with severe multi-organ disease

A score of 0.8 for a complex chronic patient is a red flag — it signals missed documentation, lost HCCs, or coding gaps rather than actual patient health status.

Common Misconceptions

• "A low score means healthy patients." Low scores often indicate incomplete documentation or coding gaps rather than actual good health. The distinction between a healthy population and an under-coded one is invisible in the data alone.
• "Chronic conditions carry over automatically." Every HCC must be re-documented annually through a qualified face-to-face provider visit. The CMS-HCC model resets each payment year — conditions not recaptured fall off the RAF score entirely.
• "Higher scores are always better." Inflated or unsupported RAF scores trigger RADV audit risk. CMS estimates 9.5% of MA payments are improper due to unsupported diagnoses. Plans with year-over-year RAF variations exceeding 15% face heightened scrutiny.
• "RAF scores capture all health risk factors." The CMS-HCC model does not account for social determinants of health, behavioral health complexity, or care access barriers.
• "The calculation hasn't changed much." V28 is a ground-up rebuild. Plans still running V24-era assumptions will systematically misestimate revenue and risk exposure.

How Payers and Providers Use RAF Scores

Payers and providers interact with RAF scores differently, though both depend on accuracy.

Medicare Advantage Plans

• Revenue Forecasting: RAF directly determines CMS capitation — it is the top-line revenue driver
• Risk Gap Identification: Comparing expected vs. actual RAF reveals missed HCCs and underpayment at both member and population level
• RADV Compliance: Ensuring every HCC supporting a RAF score has proper clinical documentation
• Care Management Targeting: Higher-RAF members are prioritized for intervention programs

Providers

• Capitated Contracts: Per-patient capitation amounts are adjusted based on RAF — directly impacting provider revenue in risk-bearing arrangements
• ACO Shared Savings: RAF scores adjust cost benchmarks so providers caring for complex patients are not unfairly penalized
• Clinical Documentation Improvement: RAF analysis reveals documentation gaps where true patient complexity is not captured in the medical record
• Quality Measurement: Risk-adjusted quality metrics use RAF scores to normalize performance comparisons across provider panels

Understanding risk adjustment at the organizational level is what connects individual RAF scores to sustainable financial and clinical outcomes.

Checking and Improving RAF Scores

• Individual Calculations: The free RAF Score Calculator supports up to 50 ICD-10 codes per calculation with V28, V24, ESRD, and RxHCC models — no registration required.
• Real-Time API Integration: The RAF Score API provides patient-level risk calculations with care gap analysis, designed for EHR and population health platform integration.
• Population-Level Analysis: RAF Batch Processing handles 100,000+ member records per batch for pre-audit analysis, underpayment identification, and risk trend tracking.