Risk Adjustment Program Compensation: Fewer Targets, Greater Opportunities

Effective Jan. 1, 2027, Highmark will make slight modifications to our prospective risk adjustment program compensation model in all markets and lines of business. These modifications are designed to simplify our Risk Score Accuracy (RSA) and Unconfirmed Diagnosis Code (UDC) programs, making it easier for providers to focus on and achieve key targets.

Our updated compensation model promotes flexible and simple program participation, recognizes higher performance, and enables greater provider engagement to address open diagnosis gaps.

What is Changing

1. Removal of four high-prevalence Part D conditions from targeting

We heard you throughout 2026 and want to limit the gaps that we are asking you to assess to a more manageable volume.

The following measures will no longer be included in the program targeting methodology:

• Prescription Hierarchical Condition Category (RxHCC) 44 – Thyroid Disorders
• 133 – Anxiety and Other Psychiatric Disorders
• 187 – Hypertension
• 188 – Coronary Artery Disease

2. Changes to bonus tiers for per-gap payments

For our Medicare Advantage (MA) and Dual-Eligible Special Needs Plan (D-SNP) membership, we have added a larger tiered bonus for 75% assessment, bridging the gap between the existing 70% and 80% bonus thresholds. As part of this update, we have eliminated the tiered bonus for 60% – 69.99% assessment rates.

See the matrix below for updated MA and D-SNP per-gap payments:

*Base payments are made quarterly; bonus payments are paid annually at year-end.

Similarly, for our Affordable Care Act (ACA) membership, we have added a larger tiered bonus for 65% assessment, bridging the gap between the existing 60% and 70% bonus thresholds, while eliminating the tiered bonus for 50% – 59.99% assessment rates.

See the matrix below for updated ACA per-gap payments:

*Base payments are made quarterly; bonus payments are paid annually at year-end.

Lastly, for our Medicaid membership, we’ve increased the Tier 1 bonus payment so that once 70% of gaps have been assessed, providers will receive $20 per gap, and we’ve added Tiers 2 and 3 for additional opportunity.

See the matrix below for updated Medicaid payments:

*Base payments are made quarterly; bonus payments are paid annually at year-end.

Where Can I Learn More?

As we approach the new year, additional resources will be made available on the Risk Adjustment Programs page on the Provider Resource Center (PRC). (Note: You must be logged in to Availity Essentials^® to view this proprietary content.)

If you are already participating in Highmark’s RSA or UDC programs, your primary Highmark risk adjustment contact will also be able to assist with any questions and comments.

Highmark is committed to regularly reviewing our program structure to ensure our members receive better healthcare outcomes and provide our partners with competitive program benefits.