How are cumulative risk scores used in Medicare Advantage plans?

• A. To determine future funding allocations
• B. To measure staff performance
• C. To set clinic hours
• D. To count patient visits

Answer: (A)

Cumulative risk scores are about adjusting payments to Medicare Advantage plans based on how sick the enrolled population is. Each enrollee’s health status is summarized into a risk score, which estimates their expected overall medical costs for the coming year. When a plan’s enrollees’ risk scores are combined, this determines how much funding the plan should receive in the next funding cycle. Higher risk scores mean higher payments to cover anticipated costs, while lower scores lead to lower payments. This risk adjustment helps ensure plans are funded fairly for the mix of health needs they serve.

These scores aren’t used to measure staff performance, set clinic hours, or count patient visits, which are operational or utilization issues rather than funding decisions.