Comparison of HCC Coding: Types – ACA & MA
Hierarchical Condition Category (HCC) coding is a risk-adjustment model used to predict healthcare costs based on patient diagnoses. It is widely used for reimbursement and risk adjustment in value-based care models.
Two Major Types of HCC Coding:
ACA HCC (Affordable Care Act HCCs)
- Used for commercial insurance plans under the Affordable Care Act (ACA) risk adjustment model.
- Applies to individual and small-group marketplace plans.
- Helps adjust payments to health plans based on the health risk of enrollees.
- Uses a different HCC model than Medicare Advantage, focusing on broader populations.
MA HCC (Medicare Advantage HCCs)
- Used for Medicare Advantage (MA) plans to determine capitated payments from CMS (Centers for Medicare & Medicaid Services).
- Focuses on elderly and disabled populations enrolled in Medicare Advantage.
- Uses a risk adjustment model to ensure appropriate reimbursement based on chronic conditions.
- More focused on chronic diseases commonly found in senior populations (e.g., diabetes, CHF, COPD).
Key Differences Between ACA & MA HCC Models
Why HCC Coding Matters?
- Accurate Risk Adjustment: Ensures fair reimbursement for healthcare plans based on patient complexity.
- Improved Healthcare Outcomes: Helps identify and manage high-risk patients.
- Compliance & Revenue Integrity: Ensures proper documentation and payment alignment with regulatory guidelines.
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