Certified Risk Adjustment Coder (CRC)

Which of the following is true regarding the risk adjustment model by HHS?

1. States are mandated to use the Medicare HCCs.

2. States must use the federal methodology exclusively.

3. States can propose an alternate methodology for certification.

4. States can disregard risk adjustment logic from reimbursement.

The correct answer is: States can propose an alternate methodology for certification.

The correct choice highlights an essential aspect of the risk adjustment model utilized by the Department of Health and Human Services (HHS). States have the flexibility to propose an alternative risk adjustment methodology for certification, which allows for some degree of customization in how they approach issues related to risk adjustment in their specific populations. This provision recognizes that different states may have unique healthcare environments and needs that warrant tailored solutions. The other options do not align with the guidelines provided by HHS. For example, looking at the first option, there is no requirement for states to use the Medicare Hierarchical Condition Categories (HCCs) specifically; rather, they can develop their models as long as they meet certain criteria established by the federal guidelines. Similarly, while the second option suggests that states must use federally prescribed methodologies exclusively, that minimizes states' ability to innovate and adapt. The fourth option stating that states could disregard risk adjustment logic from reimbursement overlooks the foundational principle of risk adjustment, which aims to account for the health status of enrollees when determining funding and reimbursement. Thus, the capacity for states to propose alternate methodologies is critical for a responsive and effective healthcare system.