Risk Adjustment Programs: New Compensation Model for 2026

Effective Jan. 1, 2026, Highmark will implement a new prospective risk adjustment program compensation model for all markets and lines of business. This new model will allow for flexible and easier program participation, recognize higher performance, and increase targeted gap opportunity.

What Programs Are Affected

The Unconfirmed Diagnosis Code (UDC) and Risk Score Accuracy (RSA) programs will incorporate this new compensation model. Important: No changes to the True Performance Lite and Vatica/eAWV compensation are occurring in 2026.

What Is Changing

To continue our focus on improving member outcomes and that conditions are being addressed appropriately, Highmark is aligning compensation with outcomes for our entire member population.

The new compensation model will be multifaceted to meet providers where they are and incorporate risk adjustment gap closure requirements into their preferred existing workflow.

• Straightforward Gap Compensation
  • All Hierarchical Condition Category (HCC) gap types, persistent and suspect, will have the same monetary value at a per-gap base compensation rate.
• Availability of Additional Gaps
  • Medicare Part D HCC gaps will now be in scope for risk adjustment programs increasing the opportunity to earn. We are working with our risk adjustment program vendors currently and throughout 2026 to incorporate Part D HCC gaps into their point-of-care tool that presents and manages HCC gaps.
• Risk Adjustment Enablement (RAE) PMPM
  • An opportunity to earn a per member per month (PMPM) compensation (in addition to per-gap compensation) for developing a deeper collaboration with the Highmark risk team through point-of-care solution utilization, governance and education, and access to medical records and clinical information.
• Tiered Threshold Assessment
  • Providers can further increase their compensation with population-based comprehensive care by addressing a higher percentage of targeted risk conditions. Higher percentage tiers can earn additional compensation per gap.

Where Can I Learn More?

Additional resources will be available on the Risk Adjustment Programs page on the Provider Resource Center (PRC) next month.

• Log into Availity Essentials^®, select your state, go to Payer Spaces, and choose Provider Resource Center from the applications.
• Once on the PRC, select Resources & Education > Clinical Quality & Education > Risk Adjustment Programs.

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