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RxHCC Model

The second major HCC based risk adjustment model is the RxHCC model. The RxHCC model was created for Medicare Part D and Medicare Advantage plans. This model, like the CMS HCC model, can predict benefit costs that the plan will be responsible for covering and adjust standardized payments based on the underlying health status of the plan’s members.

Rx condition categories describe major diseases and are broadly organized into body systems. Like the HCC model, they’re also categorized into hierarchies. This prevents multiple diagnoses in the same disease group from increasing the risk score when they shouldn’t.

An RxHCC risk score of 1.0 means a member covered by standard Part D Medicare benefits is expected to incur the average liability amount for prescription drugs.

These are some examples of RxHCC diagnoses that are commonly overlooked in yearly reports:

RxHCC Diagnoses ICD-10 Code
134 Major depressive disorder, single episode, unspecified F32.9
188 Old myocardial infarction I25.2
187 Essential (primary) hypertension I10
166 Most Migraine diagnoses G43.001-G43.919
87 Age related osteoporosis without current pathological fracture M81.0
68 Gastroesophageal reflux disease without esophagitis K21.9
45 Pure hypercholesterolemia E78.00
42 Hypothyroidism, unspecified E03.9
226 Mild persistent asthma, uncomplicated J45.30
226 Mild intermittent asthma, uncomplicated J45.20
315 Psoriasis vulgaris L40.0


CMS website Medicare Managed Care Manual Chapter 7 Risk Adjustment