What Is a RAF Score?

RAF Score Definition (In Plain Language)

A Risk Adjustment Factor (RAF) score is a numeric value that represents a patient's expected healthcare costs relative to an average Medicare beneficiary. The higher the RAF score, the more CMS expects that member to cost—and the higher the payment a Medicare Advantage plan receives to care for that member.

Think of it this way:

• A RAF score of 1.0 represents an average Medicare beneficiary
• A RAF score of 1.5 indicates a member expected to cost 50% more than average
• A RAF score of 0.8 indicates a member expected to cost 20% less than average

What Impacts RAF: Diagnoses and Demographics

RAF scores are calculated based on two primary inputs:

Diagnoses (via HCC Mapping)

Medical diagnoses documented during clinical encounters are mapped to Hierarchical Condition Categories (HCCs). Each HCC has an associated coefficient that contributes to the RAF score. More chronic and complex conditions generally have higher coefficients.

Demographics

Basic demographic factors also contribute to RAF:

• Age: Older members generally have higher baseline RAF contributions
• Gender: Different baseline coefficients for male and female members
• Eligibility status: Dual-eligible members (Medicare + Medicaid) have separate models
• Institutional status: Members in long-term care have different risk profiles

How HCCs Relate to RAF (Conceptual)

HCCs are groupings of related diagnoses that CMS uses to predict healthcare costs:

• Not all ICD-10 codes map to HCCs—only those predictive of future costs
• HCCs are hierarchical—when multiple related HCCs are present, only the highest-value one counts
• Some HCC combinations create interaction effects that increase (or decrease) RAF
• HCCs must be documented annually to be counted in RAF calculations

Why RAF Changes Year to Year

RAF scores aren't static—they change based on several factors:

• Documentation changes: Conditions documented one year may not be documented the next
• Model updates: CMS periodically updates HCC coefficients and model versions
• Aging effects: Members move into higher age brackets over time
• Health status changes: Conditions may resolve, worsen, or new ones may develop
• Coding changes: ICD-10 updates may affect HCC mappings

When to Calculate vs When to Automate

Organizations have different RAF calculation needs: