Certified Risk Adjustment Coder (CRC)

Which RA model is most commonly used by Medicaid?

1. HCC

2. CDPS

3. Blended

4. Fee for Services (FFS)

The correct answer is: CDPS

The most commonly used risk adjustment model by Medicaid is the Chronic Illness and Disability Payment System (CDPS). This model is specifically designed to accommodate the unique needs of Medicaid populations, which often include individuals with complex chronic conditions and disabilities. The CDPS categorizes enrollees based on their health status and needs, allowing for more accurate risk adjustment and reflecting the costs associated with their care. Unlike the Hierarchical Condition Categories (HCC) model, which is often used by Medicare and primarily focuses on coding chronic conditions, CDPS includes a broader range of health-related factors relevant to the predominantly low-income population served by Medicaid. It takes into account various demographic factors alongside clinical diagnoses, thereby ensuring providers receive appropriate reimbursement for the care of members who require significant medical attention. The blended model, while notable, combines methods from both HCC and other models for use in specific situations but is not as widely implemented for standard Medicaid purposes. Fee-for-Service (FFS) reimbursement models do not include risk adjustment mechanisms and focus instead on paying providers for each service performed, which does not align with the objectives of a risk-adjusted payment system. Therefore, CDPS stands out as the most suitable and applied model for Medicaid's risk adjustment needs.