How the RxHCC model scores a beneficiary
A Part D risk score adds up the relative factors that apply to one beneficiary in one segment. Continuing enrollees in the community are scored in four segments, by whether they receive the Part D low-income subsidy and whether they are 65 or older; beneficiaries in long-term institutions have a fifth segment, and new enrollees have three of their own (non-low income, low income, institutional) that use only age, sex and originally-disabled and ESRD status. The score starts with the age and sex factor, adds an originally-disabled factor for beneficiaries 65 or older who first qualified through disability, adds the factor of every RxHCC left after the hierarchy, and in the institutional segment adds an extra factor for seven categories when the beneficiary is under 65. Unlike CMS-HCC V28, the RxHCC model has no disease-pair interactions and no factor for the number of categories.
For payment year 2027 CMS scores MA-PD plans and standalone PDPs with separate factors from one model calibrated on 2023 diagnoses and 2024 drug costs, reflecting the Part D benefit changes of the Inflation Reduction Act. The CY2027 Rate Announcement of April 6, 2026 sets the normalization factors at 1.109 for MA-PD plans and 1.005 for PDPs. PACE organizations are scored on a 50/50 blend of that model (MA-PD factors) and the model calibrated on 2018/2019 data, normalized at 1.237. The factors on this page come from the CMS software packages R0826.84.Y1, R0826.84.Y2 and R0826.84.T2; each package's 420 continuing enrollee category factors were checked against Tables VIII-1, VIII-5 and VIII-9 of the Rate Announcement and match them exactly. In the MA-PD factors, 61 of the 84 categories are worth more for low-income beneficiaries 65 or older than for other beneficiaries of that age, and the originally-disabled factor for a low-income woman is 0.384 against 0.046 without the subsidy.
One category across all five continuing enrollee segments and the three calibrations: RxHCC 30, diabetes with complications, which 423 ICD-10-CM codes map to.
| Segment | MA-PD | PDP | PACE (2018/2019) |
|---|---|---|---|
| Community, non-low income, 65 or older | 0.429 | 0.616 | 0.499 |
| Community, non-low income, under 65 | 0.618 | 0.629 | 0.539 |
| Community, low income, 65 or older | 0.852 | 0.953 | 0.944 |
| Community, low income, under 65 | 1.443 | 1.306 | 1.432 |
| Long-term institutional | 0.633 | 0.602 | 0.908 |
RxHCC compared with CMS-HCC V28
| RxHCC V08 (Part D) | CMS-HCC V28 (Part C) | |
|---|---|---|
| Payment categories | 84 | 115 |
| Mapped ICD-10-CM codes (PY2027 initial) | 5,385 | 8,019 |
| Continuing enrollee segments | Low-income subsidy and age 65, plus institutional (5) | Medicaid dual status and age 65, plus institutional (7) |
| Interaction terms | Under-65 terms for 7 categories, institutional only | 6 disease pairs, 5 disabled terms (institutional) |
| Category count factor | None | Yes, from 5 payment HCCs (10 in the institutional segment) |
| 2027 normalization factor | 1.109 MA-PD, 1.005 PDP | 1.079, then the 5.90% MA coding adjustment |
4,056 codes map to both an RxHCC and a V28 payment category, 1,329 map only to an RxHCC and 3,963 only to a V28 category, so one documented diagnosis can count in both models, in one, or in neither. 15 RxHCCs have no V28 counterpart for any of their codes, among them RxHCC 47 (Disorders of Lipoid Metabolism), RxHCC 55 (Acute or Unspecified Viral Hepatitis C), RxHCC 66 (Pancreatic Disorders and Intestinal Malabsorption, Except Pancreatitis) and RxHCC 146 (Profound or Severe Intellectual Disability/Developmental Disorder). The categories with the most Part D-only codes are below: their codes add to the Part D score but to no CMS-HCC V28 category. The CMS-HCC V28 hub covers the Part C side, and the HCC lookup shows both categories for any code you enter.
| RxHCC | Category | Part D-only codes | All codes |
|---|---|---|---|
| RxHCC 43 | Pituitary, Adrenal Gland, and Other Endocrine and Metabolic Disorders | 187 | 214 |
| RxHCC 244 | Other Non-Acute Glaucoma | 179 | 179 |
| RxHCC 87 | Osteoporosis, Vertebral and Pathological Fractures | 149 | 178 |
| RxHCC 243 | Glaucoma, Open-Angle or Moderate/Severe Stage | 135 | 135 |
| RxHCC 133 | Anxiety and Other Psychiatric Disorders | 106 | 143 |
| RxHCC 30 | Diabetes with Complications | 85 | 423 |
| RxHCC 188 | Coronary Artery Disease | 54 | 97 |
| RxHCC 166 | Migraine Headaches | 48 | 48 |
Highest relative factors
Multiple Myeloma and Other Hematologic Cancers, HIV/AIDS and Cystic Fibrosis carry the highest factors. A factor above 1.000 means the category alone adds more than the whole risk score of an average beneficiary (1.000). The same category usually carries a different factor in the low-income, under-65 and institutional segments, shown alongside.
| RxHCC | Category | Non-LI 65+ | LI 65+ | Non-LI <65 | Institutional |
|---|---|---|---|---|---|
| RxHCC 16 | Multiple Myeloma and Other Hematologic Cancers | 13.265 | 12.257 | 11.777 | 5.921 |
| RxHCC 1 | HIV/AIDS | 8.304 | 9.495 | 9.870 | 7.923 |
| RxHCC 225 | Cystic Fibrosis | 8.032 | 6.036 | 42.156 | 5.260 |
| RxHCC 98 | Hereditary Angioedema and Other Defects in the Complement System | 6.992 | 7.999 | 38.627 | 4.374 |
| RxHCC 15 | Chronic Myeloid Leukemia | 5.500 | 15.374 | 5.147 | 8.699 |
| RxHCC 17 | Secondary Cancer of Bone and Kidney | 5.500 | 12.166 | 5.147 | 5.594 |
| RxHCC 157 | Chronic Inflammatory Demyelinating Polyneuritis | 4.803 | 6.163 | 9.149 | 1.510 |
| RxHCC 41 | Lysosomal Storage Disorders | 4.133 | 4.392 | 11.642 | 0.141 |
| RxHCC 395 | Stem Cell, Including Bone Marrow, Transplant Status/Complications | 3.930 | 5.263 | 3.941 | 3.069 |
| RxHCC 154 | Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease | 3.827 | 2.505 | 3.734 | 0.549 |
MA-PD and standalone PDP factors
For payment year 2027 the continuing enrollee segments carry separate factors for MA-PD plans and standalone PDPs, whose enrollees' drug spending differs for the same conditions. In the non-low income, 65 or older segment 59 of the 84 categories carry a higher PDP factor and 14 a lower one; the largest differences are below.
| RxHCC | Category | MA-PD | PDP | Difference |
|---|---|---|---|---|
| RxHCC 225 | Cystic Fibrosis | 8.032 | 19.750 | +11.718 |
| RxHCC 98 | Hereditary Angioedema and Other Defects in the Complement System | 6.992 | 11.918 | +4.926 |
| RxHCC 41 | Lysosomal Storage Disorders | 4.133 | 8.193 | +4.060 |
| RxHCC 183 | Pulmonary Arterial Hypertension | 1.901 | 3.492 | +1.591 |
| RxHCC 1 | HIV/AIDS | 8.304 | 9.794 | +1.490 |
| RxHCC 154 | Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease | 3.827 | 4.954 | +1.127 |
| RxHCC 226 | Idiopathic Pulmonary Fibrosis and Systemic Sclerosis with Lung Involvement | 2.752 | 3.873 | +1.121 |
| RxHCC 16 | Multiple Myeloma and Other Hematologic Cancers | 13.265 | 14.286 | +1.021 |
RxHCC hierarchies
36 rules in 14 condition groups (neoplasm, diabetes, metabolic, liver, gastrointestinal, musculoskeletal, cognitive, psychiatric, developmental disability, neurological, heart, lung, eye, kidney) rank related categories. When the category in the first column is present, the categories in the second are dropped, so a beneficiary is paid only for the most severe condition in each group.
| Group | If present | Drops |
|---|---|---|
| Neoplasm | RxHCC 15 Chronic Myeloid Leukemia | RxHCC 17, RxHCC 18, RxHCC 19, RxHCC 20, RxHCC 21, RxHCC 22 |
| Neoplasm | RxHCC 16 Multiple Myeloma and Other Hematologic Cancers | RxHCC 17, RxHCC 18, RxHCC 19, RxHCC 20, RxHCC 21, RxHCC 22 |
| Neoplasm | RxHCC 17 Secondary Cancer of Bone and Kidney | RxHCC 18, RxHCC 19, RxHCC 20, RxHCC 21, RxHCC 22 |
| Neoplasm | RxHCC 18 Secondary Cancer of Lung, Liver, Brain, and Other Sites | RxHCC 19, RxHCC 20, RxHCC 21, RxHCC 22 |
| Neoplasm | RxHCC 19 Leukemias and Other Hematologic Cancers | RxHCC 20, RxHCC 21, RxHCC 22 |
| Neoplasm | RxHCC 20 Lung, Kidney, and Other Cancers; Secondary Cancer of Lymph Nodes and Other Sites | RxHCC 21, RxHCC 22 |
| Neoplasm | RxHCC 21 Lymphomas and Other Hematologic Cancers | RxHCC 22 |
| Diabetes | RxHCC 30 Diabetes with Complications | RxHCC 31 |
| Metabolic | RxHCC 40 Alpha-1-Antitrypsin Deficiency | RxHCC 43 |
| Metabolic | RxHCC 41 Lysosomal Storage Disorders | RxHCC 43 |
| Metabolic | RxHCC 42 Acromegaly and Other Endocrine and Metabolic Disorders | RxHCC 43 |
| Liver | RxHCC 54 Chronic Viral Hepatitis C | RxHCC 55 |
| Gastrointestinal | RxHCC 65 Chronic Pancreatitis | RxHCC 66 |
| Musculoskeletal | RxHCC 81 Psoriatic Arthropathy | RxHCC 83, RxHCC 84, RxHCC 316 |
| Musculoskeletal | RxHCC 82 Systemic Sclerosis | RxHCC 83, RxHCC 84 |
| Musculoskeletal | RxHCC 83 Rheumatoid Arthritis and Other Inflammatory Polyarthropathy | RxHCC 84 |
| Musculoskeletal | RxHCC 84 Systemic Lupus Erythematosus and Other Systemic Connective Tissue Disorders | RxHCC 317 |
| Cognitive | RxHCC 111 Alzheimer's Disease | RxHCC 112 |
| Psychiatric | RxHCC 130 Schizophrenia and Other Psychosis | RxHCC 131, RxHCC 132, RxHCC 133 |
| Psychiatric | RxHCC 131 Bipolar Disorders | RxHCC 132, RxHCC 133 |
| Psychiatric | RxHCC 132 Depression | RxHCC 133 |
| Developmental disability | RxHCC 146 Profound or Severe Intellectual Disability/Developmental Disorder | RxHCC 147, RxHCC 148 |
| Developmental disability | RxHCC 147 Moderate Intellectual Disability/Developmental Disorder | RxHCC 148 |
| Neurological | RxHCC 157 Chronic Inflammatory Demyelinating Polyneuritis | RxHCC 158 |
| Neurological | RxHCC 163 Intractable Epilepsy | RxHCC 164 |
| Heart | RxHCC 183 Pulmonary Arterial Hypertension | RxHCC 184, RxHCC 186, RxHCC 187 |
| Heart | RxHCC 184 Pulmonary Hypertension, Except Arterial, and Other Pulmonary Heart Disease | RxHCC 186, RxHCC 187 |
| Heart | RxHCC 186 Heart Failure | RxHCC 187 |
| Lung | RxHCC 225 Cystic Fibrosis | RxHCC 229 |
| Lung | RxHCC 226 Idiopathic Pulmonary Fibrosis and Systemic Sclerosis with Lung Involvement | RxHCC 227, RxHCC 229 |
| Lung | RxHCC 227 Pulmonary Fibrosis, Except Idiopathic | RxHCC 229 |
| Lung | RxHCC 228 Severe Persistent Asthma | RxHCC 229 |
| Eye | RxHCC 243 Glaucoma, Open-Angle or Moderate/Severe Stage | RxHCC 244 |
| Kidney | RxHCC 260 Kidney Transplant Status | RxHCC 261, RxHCC 262, RxHCC 263, RxHCC 396 |
| Kidney | RxHCC 261 Dialysis Status, Including End Stage Renal Disease | RxHCC 262, RxHCC 263 |
| Kidney | RxHCC 262 Chronic Kidney Disease Stage 5 | RxHCC 263 |
Under-65 terms in the institutional segment
In the long-term institutional segment, 7 categories carry an extra factor when the beneficiary is under 65, on top of the category's own factor.
| RxHCC | Category | MA-PD | PDP | PACE (2018/2019) |
|---|---|---|---|---|
| RxHCC 1 | HIV/AIDS | 1.715 | 0.965 | 2.755 |
| RxHCC 130 | Schizophrenia and Other Psychosis | 1.009 | 1.054 | 0.749 |
| RxHCC 131 | Bipolar Disorders | 0.394 | 0.823 | 0.749 |
| RxHCC 132 | Depression | 0.206 | 0.275 | 0.358 |
| RxHCC 133 | Anxiety and Other Psychiatric Disorders | 0.000 | 0.275 | 0.011 |
| RxHCC 159 | Multiple Sclerosis | 1.361 | 1.982 | 3.441 |
| RxHCC 163 | Intractable Epilepsy | 0.297 | 0.285 | 0.705 |
All 84 RxHCC categories with 2027 factors
Code counts and examples come from the PY2027 initial ICD-10-CM mapping; the V28 column names the CMS-HCC categories most of the same codes map to. Factors are the MA-PD values for the community non-low income (NL) and low income (LI) segments at 65 or older and for the institutional segment, and the PDP value for community NL 65 or older; the under-65 and PACE values are in the CMS software files cited below. A dash marks a cell the Rate Announcement tables print as "-": no factor applies to that category in that segment, and the CMS software carries 0 for it.
| RxHCC | Category and example codes | Codes | CMS-HCC V28 | MA-PD NL 65+ | MA-PD LI 65+ | MA-PD inst. | PDP NL 65+ |
|---|---|---|---|---|---|---|---|
| 1 | HIV/AIDSB20 Human immunodeficiency virus [HIV] disease; B97.35 Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere; Z21 Asymptomatic human immunodeficiency virus [HIV] infection status | 3 | HCC 1 | 8.304 | 9.495 | 7.923 | 9.794 |
| 5 | Opportunistic InfectionsA07.2 Cryptosporidiosis; A31.0 Pulmonary mycobacterial infection; A31.2 Disseminated mycobacterium avium-intracellulare complex (DMAC) | 37 | HCC 6, HCC 2 | 0.603 | 0.784 | 0.350 | 0.612 |
| 15 | Chronic Myeloid LeukemiaC92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission; C92.11 Chronic myeloid leukemia, BCR/ABL-positive, in remission; C92.12 Chronic myeloid leukemia, BCR/ABL-positive, in relapse | 3 | HCC 22 | 5.500 | 15.374 | 8.699 | 6.057 |
| 16 | Multiple Myeloma and Other Hematologic CancersC90.00 Multiple myeloma not having achieved remission; C90.01 Multiple myeloma in remission; C90.02 Multiple myeloma in relapse | 15 | HCC 19 | 13.265 | 12.257 | 5.921 | 14.286 |
| 17 | Secondary Cancer of Bone and KidneyC79.00 Secondary malignant neoplasm of unspecified kidney and renal pelvis; C79.01 Secondary malignant neoplasm of right kidney and renal pelvis; C79.02 Secondary malignant neoplasm of left kidney and renal pelvis | 6 | HCC 17, HCC 18 | 5.500 | 12.166 | 5.594 | 6.057 |
| 18 | Secondary Cancer of Lung, Liver, Brain, and Other SitesC78.00 Secondary malignant neoplasm of unspecified lung; C78.01 Secondary malignant neoplasm of right lung; C78.02 Secondary malignant neoplasm of left lung | 34 | HCC 17, HCC 18 | 2.953 | 4.487 | 1.605 | 3.401 |
| 19 | Leukemias and Other Hematologic CancersC83.10 Mantle cell lymphoma, unspecified site; C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck; C83.12 Mantle cell lymphoma, intrathoracic lymph nodes | 132 | HCC 20, HCC 17, HCC 19 | 2.953 | 4.076 | 1.605 | 3.401 |
| 20 | Lung, Kidney, and Other Cancers; Secondary Cancer of Lymph Nodes and Other SitesC22.0 Liver cell carcinoma; C22.1 Intrahepatic bile duct carcinoma; C22.2 Hepatoblastoma | 74 | HCC 20, HCC 21, HCC 23 | 0.678 | 1.315 | 0.312 | 0.832 |
| 21 | Lymphomas and Other Hematologic CancersC81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site; C81.01 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck; C81.02 Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes | 405 | HCC 21, HCC 20, HCC 19 | 0.678 | 0.706 | 0.312 | 0.832 |
| 22 | Prostate, Breast, Bladder, and Other Cancers and TumorsC01 Malignant neoplasm of base of tongue; C02.0 Malignant neoplasm of dorsal surface of tongue; C02.1 Malignant neoplasm of border of tongue | 476 | HCC 23, HCC 21, HCC 22 | 0.152 | 0.427 | 0.243 | 0.150 |
| 30 | Diabetes with ComplicationsE08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC); E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma; E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma | 423 | HCC 37, HCC 298, HCC 36 | 0.429 | 0.852 | 0.633 | 0.616 |
| 31 | Diabetes without ComplicationE08.9 Diabetes mellitus due to underlying condition without complications; E09.9 Drug or chemical induced diabetes mellitus without complications; E10.9 Type 1 diabetes mellitus without complications | 6 | HCC 38 | 0.232 | 0.418 | 0.259 | 0.299 |
| 40 | Alpha-1-Antitrypsin DeficiencyE88.01 Alpha-1-antitrypsin deficiency | 1 | HCC 50 | 2.285 | 6.326 | 1.638 | 2.285 |
| 41 | Lysosomal Storage DisordersE72.04 Cystinosis; E74.02 Pompe disease; E75.00 GM2 gangliosidosis, unspecified | 38 | HCC 49 | 4.133 | 4.392 | 0.141 | 8.193 |
| 42 | Acromegaly and Other Endocrine and Metabolic DisordersE22.0 Acromegaly and pituitary gigantism; E24.0 Pituitary-dependent Cushing's disease; E70.0 Classical phenylketonuria | 10 | HCC 50, HCC 51 | 2.505 | 2.390 | 1.212 | 3.420 |
| 43 | Pituitary, Adrenal Gland, and Other Endocrine and Metabolic DisordersA39.1 Waterhouse-Friderichsen syndrome; E20.0 Idiopathic hypoparathyroidism; E20.810 Autosomal dominant hypocalcemia | 214 | HCC 50, HCC 51 | 0.023 | 0.025 | 0.141 | 0.072 |
| 44 | Thyroid DisordersE00.0 Congenital iodine-deficiency syndrome, neurological type; E00.1 Congenital iodine-deficiency syndrome, myxedematous type; E00.2 Congenital iodine-deficiency syndrome, mixed type | 48 | HCC 202 | 0.054 | 0.116 | 0.159 | 0.052 |
| 47 | Disorders of Lipoid MetabolismE71.30 Disorder of fatty-acid metabolism, unspecified; E78.00 Pure hypercholesterolemia, unspecified; E78.01 Familial hypercholesterolemia | 19 | none | — | 0.055 | 0.057 | — |
| 54 | Chronic Viral Hepatitis CB18.2 Chronic viral hepatitis C | 1 | HCC 65 | 0.211 | 0.300 | 0.533 | 0.104 |
| 55 | Acute or Unspecified Viral Hepatitis CB17.10 Acute hepatitis C without hepatic coma; B17.11 Acute hepatitis C with hepatic coma; B19.20 Unspecified viral hepatitis C without hepatic coma | 4 | none | 0.211 | 0.300 | 0.533 | 0.104 |
| 56 | Chronic Viral Hepatitis B and Other Specified Chronic Viral HepatitisB18.0 Chronic viral hepatitis B with delta-agent; B18.1 Chronic viral hepatitis B without delta-agent; B18.8 Other chronic viral hepatitis | 3 | HCC 65 | 0.140 | 1.090 | 0.931 | 0.533 |
| 59 | Primary Biliary CirrhosisK74.3 Primary biliary cirrhosis | 1 | HCC 68 | 1.035 | 1.709 | 1.447 | 1.089 |
| 65 | Chronic PancreatitisK86.0 Alcohol-induced chronic pancreatitis; K86.1 Other chronic pancreatitis | 2 | HCC 79 | 0.202 | 0.678 | 0.902 | 0.423 |
| 66 | Pancreatic Disorders and Intestinal Malabsorption, Except PancreatitisE16.3 Increased secretion of glucagon; E16.4 Increased secretion of gastrin; E16.8 Other specified disorders of pancreatic internal secretion | 23 | none | 0.202 | 0.642 | 0.483 | 0.299 |
| 67 | Inflammatory Bowel DiseaseK50.00 Crohn's disease of small intestine without complications; K50.011 Crohn's disease of small intestine with rectal bleeding; K50.012 Crohn's disease of small intestine with intestinal obstruction | 81 | HCC 81, HCC 80, HCC 78 | 0.362 | 1.250 | 0.370 | 0.551 |
| 80 | Aseptic Necrosis of BoneM87.00 Idiopathic aseptic necrosis of unspecified bone; M87.011 Idiopathic aseptic necrosis of right shoulder; M87.012 Idiopathic aseptic necrosis of left shoulder | 241 | HCC 92 | 0.103 | 0.155 | 0.543 | 0.230 |
| 81 | Psoriatic ArthropathyL40.50 Arthropathic psoriasis, unspecified; L40.51 Distal interphalangeal psoriatic arthropathy; L40.52 Psoriatic arthritis mutilans | 6 | HCC 93 | 0.719 | 6.691 | 4.194 | 0.933 |
| 82 | Systemic SclerosisM34.0 Progressive systemic sclerosis; M34.1 CR(E)ST syndrome; M34.2 Systemic sclerosis induced by drug and chemical | 8 | HCC 93, HCC 278 | 1.429 | 1.718 | 0.599 | 1.691 |
| 83 | Rheumatoid Arthritis and Other Inflammatory PolyarthropathyI77.82 Antineutrophilic cytoplasmic antibody [ANCA] vasculitis; M02.30 Reiter's disease, unspecified site; M02.311 Reiter's disease, right shoulder | 540 | HCC 93, HCC 94, HCC 280 | 0.139 | 1.225 | 0.599 | 0.172 |
| 84 | Systemic Lupus Erythematosus and Other Systemic Connective Tissue DisordersM30.0 Polyarteritis nodosa; M30.1 Polyarteritis with lung involvement [Churg-Strauss]; M30.2 Juvenile polyarteritis | 54 | HCC 94, HCC 93, HCC 112 | 0.114 | 0.339 | 0.422 | 0.146 |
| 87 | Osteoporosis, Vertebral and Pathological FracturesE55.0 Rickets, active; M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture; M48.51XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture | 178 | HCC 402, HCC 401 | 0.050 | 0.182 | 0.049 | 0.060 |
| 95 | Sickle Cell AnemiaD57.00 Hb-SS disease with crisis, unspecified; D57.01 Hb-SS disease with acute chest syndrome; D57.02 Hb-SS disease with splenic sequestration | 14 | HCC 107 | 0.014 | — | — | — |
| 96 | Acquired Hemolytic, Aplastic, and Sideroblastic AnemiasD59.0 Drug-induced autoimmune hemolytic anemia; D59.10 Autoimmune hemolytic anemia, unspecified; D59.11 Warm autoimmune hemolytic anemia | 34 | HCC 109 | 1.076 | 1.108 | 0.274 | 1.038 |
| 98 | Hereditary Angioedema and Other Defects in the Complement SystemD84.1 Defects in the complement system | 1 | HCC 115 | 6.992 | 7.999 | 4.374 | 11.918 |
| 99 | Immune DisordersD80.0 Hereditary hypogammaglobulinemia; D80.1 Nonfamilial hypogammaglobulinemia; D80.2 Selective deficiency of immunoglobulin A [IgA] | 54 | HCC 114, HCC 115 | 0.418 | 0.831 | 0.374 | 0.948 |
| 100 | Immune Thrombocytopenic PurpuraD69.3 Immune thrombocytopenic purpura | 1 | HCC 112 | 0.449 | 2.418 | 1.800 | 0.700 |
| 111 | Alzheimer's DiseaseG30.0 Alzheimer's disease with early onset; G30.1 Alzheimer's disease with late onset; G30.8 Other Alzheimer's disease | 4 | HCC 127 | — | — | — | — |
| 112 | Dementia, Except Alzheimer's DiseaseA81.00 Creutzfeldt-Jakob disease, unspecified; A81.01 Variant Creutzfeldt-Jakob disease; A81.09 Other Creutzfeldt-Jakob disease | 99 | HCC 127, HCC 125, HCC 126 | — | — | — | — |
| 130 | Schizophrenia and Other PsychosisF20.0 Paranoid schizophrenia; F20.1 Disorganized schizophrenia; F20.2 Catatonic schizophrenia | 15 | HCC 151, HCC 152 | 0.249 | 0.949 | 0.753 | 0.362 |
| 131 | Bipolar DisordersF30.10 Manic episode without psychotic symptoms, unspecified; F30.11 Manic episode without psychotic symptoms, mild; F30.12 Manic episode without psychotic symptoms, moderate | 37 | HCC 154, HCC 152 | 0.225 | 0.680 | 0.629 | 0.324 |
| 132 | DepressionF32.0 Major depressive disorder, single episode, mild; F32.1 Major depressive disorder, single episode, moderate; F32.2 Major depressive disorder, single episode, severe without psychotic features | 393 | HCC 155, HCC 152 | 0.040 | 0.083 | 0.169 | 0.039 |
| 133 | Anxiety and Other Psychiatric DisordersF21 Schizotypal disorder; F22 Delusional disorders; F24 Shared psychotic disorder | 143 | HCC 153, HCC 152 | 0.023 | — | — | 0.009 |
| 146 | Profound or Severe Intellectual Disability/Developmental DisorderF72 Severe intellectual disabilities; F73 Profound intellectual disabilities | 2 | none | 0.811 | 0.331 | — | 1.009 |
| 147 | Moderate Intellectual Disability/Developmental DisorderF71 Moderate intellectual disabilities; F78.A1 SYNGAP1-related intellectual disability | 2 | none | 0.811 | 0.175 | — | 1.009 |
| 148 | Mild or Unspecified Intellectual Disability/Developmental DisorderF70 Mild intellectual disabilities; F78.A9 Other genetic related intellectual disability; F79 Unspecified intellectual disabilities | 39 | none | 0.811 | 0.030 | — | 1.009 |
| 153 | Myasthenia Gravis and Other Myoneural DisordersG70.00 Myasthenia gravis without (acute) exacerbation; G70.01 Myasthenia gravis with (acute) exacerbation; G70.1 Toxic myoneural disorders | 10 | HCC 196, HCC 195 | 2.067 | 2.466 | 1.073 | 2.558 |
| 154 | Amyotrophic Lateral Sclerosis and Other Motor Neuron DiseaseG12.20 Motor neuron disease, unspecified; G12.21 Amyotrophic lateral sclerosis; G12.22 Progressive bulbar palsy | 7 | HCC 190 | 3.827 | 2.505 | 0.549 | 4.954 |
| 155 | Spinal Cord DisordersB00.82 Herpes simplex myelitis; B01.12 Varicella myelitis; B02.24 Postherpetic myelitis | 71 | HCC 182, HCC 190 | 0.054 | — | — | 0.099 |
| 157 | Chronic Inflammatory Demyelinating PolyneuritisG61.81 Chronic inflammatory demyelinating polyneuritis; G61.82 Multifocal motor neuropathy | 2 | HCC 193 | 4.803 | 6.163 | 1.510 | 5.388 |
| 158 | Inflammatory and Toxic NeuropathyD86.82 Multiple cranial nerve palsies in sarcoidosis; G13.0 Paraneoplastic neuromyopathy and neuropathy; G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic disease | 40 | HCC 93 | — | — | 0.202 | 0.085 |
| 159 | Multiple SclerosisG35 Multiple sclerosis; G35.A Relapsing-remitting multiple sclerosis; G35.B0 Primary progressive multiple sclerosis, unspecified | 12 | HCC 198 | 0.681 | 2.629 | 1.376 | 1.087 |
| 160 | Huntington DiseaseG10 Huntington's disease | 1 | HCC 200 | 1.957 | 5.473 | 5.822 | 2.477 |
| 161 | Parkinson DiseaseG20.A1 Parkinson's disease without dyskinesia, without mention of fluctuations; G20.A2 Parkinson's disease without dyskinesia, with fluctuations; G20.B1 Parkinson's disease with dyskinesia, without mention of fluctuations | 19 | HCC 199 | 0.320 | 0.592 | 1.094 | 0.498 |
| 163 | Intractable EpilepsyG40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus; G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus; G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus | 29 | HCC 201 | — | 0.229 | 0.023 | 0.107 |
| 164 | Epilepsy and Other Seizure Disorders, Except Intractable EpilepsyG40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus; G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus; G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus | 30 | HCC 201 | — | — | — | — |
| 166 | Migraine HeadachesG43.001 Migraine without aura, not intractable, with status migrainosus; G43.009 Migraine without aura, not intractable, without status migrainosus; G43.011 Migraine without aura, intractable, with status migrainosus | 48 | none | 0.107 | 0.466 | 0.687 | 0.139 |
| 168 | Trigeminal and Postherpetic NeuralgiaB02.21 Postherpetic geniculate ganglionitis; B02.22 Postherpetic trigeminal neuralgia; B02.23 Postherpetic polyneuropathy | 8 | none | 0.039 | 0.134 | — | 0.045 |
| 183 | Pulmonary Arterial HypertensionI27.0 Primary pulmonary hypertension; I27.21 Secondary pulmonary arterial hypertension; I27.83 Eisenmenger's syndrome | 3 | HCC 226 | 1.901 | 2.495 | 0.638 | 3.492 |
| 184 | Pulmonary Hypertension, Except Arterial, and Other Pulmonary Heart DiseaseI27.1 Kyphoscoliotic heart disease; I27.20 Pulmonary hypertension, unspecified; I27.22 Pulmonary hypertension due to left heart disease | 14 | HCC 226, HCC 267 | 0.232 | 0.210 | 0.327 | 0.357 |
| 186 | Heart FailureA36.81 Diphtheritic cardiomyopathy; B33.24 Viral cardiomyopathy; I09.81 Rheumatic heart failure | 47 | HCC 226, HCC 227, HCC 225 | 0.163 | 0.170 | 0.220 | 0.260 |
| 187 | HypertensionI10 Essential (primary) hypertension; I11.9 Hypertensive heart disease without heart failure; I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease | 17 | HCC 326 | 0.045 | 0.069 | 0.048 | 0.032 |
| 188 | Coronary Artery DiseaseI20.0 Unstable angina; I20.1 Angina pectoris with documented spasm; I20.2 Refractory angina pectoris | 97 | HCC 229, HCC 228 | 0.066 | 0.129 | — | 0.036 |
| 191 | Ventricular Septal Defect and Major Congenital Heart DisordersI27.840 Fontan-associated liver disease [FALD]; I27.841 Fontan-associated lymphatic dysfunction; I27.848 Other Fontan-associated condition | 29 | none | 0.138 | 0.506 | — | 0.335 |
| 193 | Atrial ArrhythmiasI47.10 Supraventricular tachycardia, unspecified; I47.11 Inappropriate sinus tachycardia, so stated; I47.19 Other supraventricular tachycardia | 14 | HCC 238 | 0.231 | 0.237 | 0.220 | 0.238 |
| 207 | Spastic HemiplegiaG81.10 Spastic hemiplegia affecting unspecified side; G81.11 Spastic hemiplegia affecting right dominant side; G81.12 Spastic hemiplegia affecting left dominant side | 5 | HCC 253 | — | — | — | — |
| 215 | Venous ThromboembolismI26.01 Septic pulmonary embolism with acute cor pulmonale; I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale; I26.03 Cement embolism of pulmonary artery with acute cor pulmonale | 164 | HCC 267 | 0.257 | 0.264 | 0.178 | 0.239 |
| 225 | Cystic FibrosisE84.0 Cystic fibrosis with pulmonary manifestations; E84.11 Meconium ileus in cystic fibrosis; E84.19 Cystic fibrosis with other intestinal manifestations | 5 | HCC 277 | 8.032 | 6.036 | 5.260 | 19.750 |
| 226 | Idiopathic Pulmonary Fibrosis and Systemic Sclerosis with Lung InvolvementJ84.112 Idiopathic pulmonary fibrosis; J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere; M34.81 Systemic sclerosis with lung involvement | 3 | HCC 278, HCC 93 | 2.752 | 5.621 | 1.241 | 3.873 |
| 227 | Pulmonary Fibrosis, Except IdiopathicB44.81 Allergic bronchopulmonary aspergillosis; D86.0 Sarcoidosis of lung; D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes | 32 | HCC 280, HCC 93, HCC 94 | 0.273 | 0.457 | 0.460 | 0.576 |
| 228 | Severe Persistent AsthmaJ45.50 Severe persistent asthma, uncomplicated; J45.51 Severe persistent asthma with (acute) exacerbation; J45.52 Severe persistent asthma with status asthmaticus | 3 | HCC 279 | 0.904 | 3.068 | 1.685 | 0.795 |
| 229 | Chronic Obstructive Pulmonary Disease, Bronchiectasis, and Other AsthmaJ41.0 Simple chronic bronchitis; J41.1 Mucopurulent chronic bronchitis; J41.8 Mixed simple and mucopurulent chronic bronchitis | 36 | HCC 280 | 0.170 | 0.365 | 0.460 | 0.192 |
| 243 | Glaucoma, Open-Angle or Moderate/Severe StageH40.10X0 Unspecified open-angle glaucoma, stage unspecified; H40.10X1 Unspecified open-angle glaucoma, mild stage; H40.10X2 Unspecified open-angle glaucoma, moderate stage | 135 | none | 0.095 | 0.269 | 0.281 | 0.124 |
| 244 | Other Non-Acute GlaucomaH40.10X0 Unspecified open-angle glaucoma, stage unspecified; H40.10X1 Unspecified open-angle glaucoma, mild stage; H40.10X4 Unspecified open-angle glaucoma, indeterminate stage | 179 | none | 0.022 | 0.072 | 0.009 | 0.019 |
| 260 | Kidney Transplant StatusT86.10 Unspecified complication of kidney transplant; T86.11 Kidney transplant rejection; T86.12 Kidney transplant failure | 7 | none | — | — | — | — |
| 261 | Dialysis Status, Including End Stage Renal DiseaseN18.6 End stage renal disease; T81.502A Unspecified complication of foreign body accidentally left in body following kidney dialysis, initial encounter; T81.512A Adhesions due to foreign body accidentally left in body following kidney dialysis, initial encounter | 25 | HCC 326 | — | — | — | — |
| 262 | Chronic Kidney Disease Stage 5I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease; I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease; I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease | 4 | HCC 326, HCC 226 | — | — | — | — |
| 263 | Chronic Kidney Disease Stage 4N18.4 Chronic kidney disease, stage 4 (severe) | 1 | HCC 327 | — | — | — | — |
| 311 | Chronic Ulcer of Skin, Except PressureE08.621 Diabetes mellitus due to underlying condition with foot ulcer; E08.622 Diabetes mellitus due to underlying condition with other skin ulcer; E09.621 Drug or chemical induced diabetes mellitus with foot ulcer | 404 | HCC 383, HCC 380, HCC 263 | 0.071 | 0.070 | 0.037 | 0.047 |
| 314 | Pemphigus, Pemphigoid, and Other Bullous Skin DisordersL10.0 Pemphigus vulgaris; L10.1 Pemphigus vegetans; L10.2 Pemphigus foliaceous | 20 | HCC 387 | 0.295 | 0.997 | 0.431 | 0.348 |
| 316 | Psoriasis, Except with ArthropathyL40.0 Psoriasis vulgaris; L40.1 Generalized pustular psoriasis; L40.2 Acrodermatitis continua | 15 | none | 0.198 | 2.104 | 1.427 | 0.286 |
| 317 | Discoid Lupus ErythematosusH01.121 Discoid lupus erythematosus of right upper eyelid; H01.122 Discoid lupus erythematosus of right lower eyelid; H01.123 Discoid lupus erythematosus of right eye, unspecified eyelid | 10 | none | 0.064 | — | — | 0.146 |
| 355 | Narcolepsy and CataplexyG47.411 Narcolepsy with cataplexy; G47.419 Narcolepsy without cataplexy; G47.421 Narcolepsy in conditions classified elsewhere with cataplexy | 4 | none | 0.888 | 2.211 | 0.898 | 1.515 |
| 395 | Stem Cell, Including Bone Marrow, Transplant Status/ComplicationsD89.810 Acute graft-versus-host disease; D89.811 Chronic graft-versus-host disease; D89.812 Acute on chronic graft-versus-host disease | 14 | HCC 454 | 3.930 | 5.263 | 3.069 | 4.047 |
| 396 | Heart, Lung, Liver, Intestine, or Pancreas Transplant StatusJ4A.0 Restrictive allograft syndrome; J4A.8 Other chronic lung allograft dysfunction; J4A.9 Chronic lung allograft dysfunction, unspecified | 39 | HCC 276, HCC 221, HCC 62 | — | — | — | — |
Documentation and the Part D score
RxHCC categories come from the same diagnosis sources as CMS-HCC: encounter data and fee-for-service claims from acceptable encounters in the data collection year, and for 2027 CMS also excludes diagnoses from audio-only services and from chart review records not linked to an encounter. A plan that offers both Part C and Part D therefore gets two scores from one set of diagnoses, and the documentation that supports a diagnosis supports it for both. Because 1,329 codes count only for Part D, a review that looks only for CMS-HCC categories misses part of the Part D picture; the HCC lookup and RAF calculator lists the RxHCC of every code next to its V28 category, and the Medicare Part D glossary entry explains the benefit the subsidy pays for.
Where QuickIntell fits for Part C and Part D risk adjustment
RxHCC categories come from the same ICD-10-CM diagnoses as CMS-HCC, so one documented and supported diagnosis can count in both models. QuickScribe captures the encounter documentation, and QuickCode supports qualified coder review and documentation clarification before diagnoses are submitted.
Frequently asked questions
What is an RxHCC?
An RxHCC is a prescription drug hierarchical condition category: a group of ICD-10-CM diagnoses that the RxHCC model uses to predict a beneficiary's Part D drug costs. CMS uses the resulting risk score to adjust the direct subsidy it pays Part D sponsors. Version 08 of the model has 84 payment categories, and 5,385 ICD-10-CM codes map to them in the payment year 2027 initial mapping.
How is the RxHCC model different from CMS-HCC?
CMS-HCC V28 adjusts Medicare Advantage Part C payments for expected medical costs; RxHCC adjusts Part D payments for expected drug costs. They read the same diagnoses but use different categories and factors. RxHCC segments split beneficiaries by low-income status and by age 65, not by Medicaid dual status, and the model has no disease interaction terms or payment HCC count factors. Of the mapped codes, 1,329 count only for RxHCC, among them the glaucoma codes and most osteoporosis codes.
Which RxHCC factors apply in 2027?
For payment year 2027 CMS uses the model calibrated on 2023 diagnoses and 2024 costs, with separate factors for MA-PD plans and standalone prescription drug plans (CMS software R0826.84.Y1 and R0826.84.Y2). PACE organizations are paid on a 50/50 blend of that model, using the MA-PD factors, and the model calibrated on 2018/2019 data (software R0826.84.T2).
What are the RxHCC normalization factors for 2027?
The CY2027 Rate Announcement sets 1.109 for MA-PD plans and 1.005 for standalone PDPs under the 2023/2024 calibration, and 1.237 for the 2018/2019 calibration used for PACE organizations. A raw RxHCC score is divided by the factor for the plan type.
Do RxHCCs have hierarchies?
Yes. 36 hierarchy rules rank related categories so only the most severe one is paid: chronic myeloid leukemia, for example, drops the secondary, solid-tumor and other hematologic cancer categories (RxHCC 17 to 22), diabetes with complications drops diabetes without complication, and dialysis status drops chronic kidney disease stages 5 and 4. The hierarchy table on this page lists every rule.
Related reference: the 115 CMS-HCC V28 categories, the V24 to V28 crosswalk, and the glossary definitions of RxHCC and the risk adjustment factor score.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- RxHCC V08 model software, payment year 2027: relative factors for the 2023/2024 calibration, MA-PD plansVersion RxHCC software R0826.84.Y1 (PY2027 initial, 2023/2024 calibration, MA-PD plans) · effective 2027-01-01 · file R0827Y61.csvSHA-256 ba62bf93745667c8…
- RxHCC V08 model software, payment year 2027: relative factors for the 2023/2024 calibration, standalone PDPsVersion RxHCC software R0826.84.Y2 (PY2027 initial, 2023/2024 calibration, standalone PDPs) · effective 2027-01-01 · file R0827Y51.csvSHA-256 2ea5e339ff1bec60…
- RxHCC V08 model software, payment year 2027: relative factors for the 2018/2019 calibration, PACE organizationsVersion RxHCC software R0826.84.T2 (PY2027 initial, 2018/2019 calibration, PACE organizations) · effective 2027-01-01 · file R0827T11.csvSHA-256 ea35798525fff592…
- ICD-10-CM to CMS-HCC V28 mappings, payment year 2027 initialVersion PY2027 initial ICD-10-CM mappings (dates of service 2026) · effective 2027-01-01 · file 2027 Initial ICD-10-CM Mappings.csvSHA-256 9c260b06d0dd2806…
- Announcement of CY2027 Medicare Advantage capitation rates and Part C and Part D payment policiesVersion CY2027 Rate Announcement (2026-04-06) · effective 2027-01-01 · file 2027-announcement.pdfSHA-256 8bb37a0969062c57…
Disclaimer
Relative factors and mappings are reproduced from the CMS RxHCC model files as an operational reference. Part D payment depends on the plan's bid, the national average monthly bid amount, normalization and the beneficiary's segment. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.