What Is a RAF Score?

The Risk Adjustment Factor (RAF) score is a numerical value assigned to each Medicare Advantage beneficiary that predicts their expected healthcare costs relative to the average Medicare beneficiary. CMS uses RAF scores to determine how much a Medicare Advantage plan is paid for each member.

A RAF score of 1.0 means the beneficiary is expected to cost the same as the average Medicare beneficiary. A score of 1.5 means 50% more costly, while a score of 0.8 means 20% less costly.

Components of a RAF Score

1. Demographic Factors

Every beneficiary starts with a baseline score determined by:

Age — Older beneficiaries generally have higher baseline scores

Sex — Male and female beneficiaries have different baseline coefficients

Eligibility status — Whether the beneficiary is community-dwelling, institutionalized, or new enrollee

Medicaid dual-eligible status — Beneficiaries eligible for both Medicare and Medicaid receive different coefficients

Disability status — Originally disabled beneficiaries under 65 have separate factors

2. HCC Coefficients

Each HCC category carries a coefficient (weight) that adds to the baseline:

Higher-severity conditions have higher coefficients

Only one HCC per hierarchy is counted (the most severe)

Coefficients differ between the V24 and V28 models

The coefficients represent the incremental cost of that condition

3. Disease Interaction Terms

Certain combinations of HCCs generate additional coefficients:

Diabetes + Heart Failure — Having both conditions together adds an interaction term beyond the individual HCC weights

COPD + Heart Failure — Another common interaction that increases the RAF score

These interactions recognize that multiple chronic conditions create compounding healthcare costs

Step-by-Step Calculation

Step 1: Establish the Demographic Baseline

Start with the appropriate demographic coefficient based on age, sex, and eligibility.

Example: A 72-year-old female, community-dwelling, non-dual-eligible might have a demographic baseline of 0.394.

Step 2: Add HCC Coefficients

For each confirmed HCC, add its coefficient:

HCC 37 (Diabetes without Complication): +0.105

HCC 226 (Heart Failure): +0.331

HCC 280 (COPD): +0.328

Running total: 0.394 + 0.105 + 0.331 + 0.328 = 1.158

Step 3: Apply Hierarchies

Check if any HCCs are in the same hierarchy. If so, only the highest-severity HCC in that hierarchy is kept.

Step 4: Add Interaction Terms

Check for disease interactions. If the patient has both Diabetes and Heart Failure, an interaction term might add +0.121.

Running total: 1.158 + 0.121 = 1.279

Step 5: Apply Payment Model Blend

In 2026, the final RAF score blends V24 and V28:

V24 RAF score × 0.33

V28 RAF score × 0.67

Final blended RAF score = sum

Why RAF Accuracy Matters

For Health Plans

Undercoded patients — The plan receives less funding than needed to cover actual healthcare costs

Overcoded patients — Creates audit risk and potential repayment obligations

Population health — Inaccurate RAF scores distort the plan's understanding of its population's health burden

For Coders

Complete capture — Ensuring every documented, MEAT-supported condition is coded

Specificity — Using the most specific ICD-10-CM code to get the correct HCC mapping

Accuracy — Only coding conditions that are supported by documentation

How HCC Buddy Helps with RAF Scores

Every code lookup in HCC Buddy shows the RAF weight for both V24 and V28 models. This lets coders immediately understand the risk adjustment impact of each code they assign.

See RAF weights instantly at hccbuddy.com/encoder.

Free resource: Download the HCC Coding Cheat Sheet — a printable V28 quick reference with top HCC categories and documentation tips.

RAF Score Calculation: A Step-by-Step Guide