Medicare Advantage plans are shifting. CMS-HCC Model V28, coming in 2026, updates how risk scores are calculated and makes sure high-risk patients get the care and resources they need. The focus is on those with multiple chronic conditions, complex care needs, or mental health challenges.
In contrast to the past models, V28 risk adjustment optimizes the process of weighting and recording the conditions. It removes obsolete codes, introduces new classes of diseases, and requires a more rigorous clinical precision. In the case of patients who are living with diabetes problems, heart failure, or severe kidney disease, these changes have a direct implication on the quality and coordination of care that they obtain. Health plans must respond quickly to avoid underfunding high-risk patients who rely on critical care resources.
Understanding CMS-HCC Model V28
The update replaces the aging V24 model that Medicare has used since 2017. CMS designed the new framework to better predict actual healthcare costs based on current medical practices and treatment expenses. The shift affects every Medicare Advantage organization and the millions of beneficiaries they serve.
What Is the CMS-HCC Model V28?
CMS-HCC Model V28 is the updated risk adjustment framework Medicare uses to predict healthcare costs for beneficiaries enrolled in Medicare Advantage plans. It assigns risk scores based on demographic factors and documented diagnoses, which determine how much CMS pays plans for each member.
The model reflects modern treatment costs and disease prevalence patterns. It recalibrates payment weights to match actual spending observed in recent Medicare fee-for-service data.
Why CMS Introduced V28
CMS designed V28 to improve payment accuracy and reduce opportunities for upcoding. The model eliminates diagnoses that do not predict costs reliably and introduces categories to the conditions that were not represented well in the past. Key drivers include outdated cost estimates, overemphasis on certain chronic conditions, gaps in mental health coding, and the need for better coordination between Medicare Advantage and traditional Medicare.
Major Changes in V28 Risk Adjustment
The CMS HCC V28 reforms the whole Hierarchical Condition Category model by introducing 115 new HCCs in comparison with the 86 categories of V24. The model provides more granular disease severity levels, improving the accuracy of cost predictions. There are large changes in the weights of the categories of payment, with some conditions having increased weight and others reduced.
How V28 Differs from V24
The new model splits several broad categories into specific severity levels. Chronic kidney disease now has five stages instead of two. Diabetes classifications separate controlled cases from those with severe complications.
V28 removes roughly 2,000 ICD-10 codes that no longer demonstrate predictive value for healthcare costs. These include outdated manifestation codes and non-specific diagnoses that were previously accepted.
Updated Coefficient Values
Payment weights for individual HCCs shift based on updated cost data. Notable adjustments include:
- Heart failure with reduced ejection fraction receives higher weighting
- Uncomplicated diabetes without organ damage carries lower coefficients
- Severe mental illness gains increased recognition in payment calculations
- Cancer categories are recalibrated based on treatment stage and prognosis
- Substance use disorders receive proper compensation under new mappings
- Advanced stages of chronic diseases requiring intensive management get appropriate funding
Impact on High-Risk Populations
High-risk populations face the most immediate effects from these changes. These are Medicare beneficiaries with multiple chronic conditions, functional limitations, or complex care requirements that generate substantial healthcare spending. The model’s refinements directly determine how much funding follows these patients for their care.
Who Qualifies as High-Risk?
High-risk patients typically have three or more chronic conditions requiring ongoing management. They account for a disproportionate share of healthcare utilization and costs within Medicare Advantage plans.
Common characteristics include:
- Multiple hospitalizations within 12 months
- Polypharmacy involving five or more prescription medications
- Functional impairments affecting activities of daily living
- Advanced chronic diseases like stage 4 kidney disease or NYHA class III heart failure
- Co-occurring mental health and substance use disorders
Changes in Care Coordination Requirements
V28 raises the bar for documenting and managing complex cases. Plans must demonstrate active treatment and regular monitoring for conditions that drive risk scores. Care teams need to:
- Document disease severity accurately at every encounter
- Track progression or improvement in chronic condition status
- Coordinate across specialists to capture all relevant diagnoses
- Address social determinants of health that complicate disease management
- Provide evidence of ongoing treatment rather than historical diagnosis mentions
Clinical Documentation Requirements
Documentation standards tighten considerably under the new model. CMS HCC V28 demands specificity that many providers haven’t consistently provided under V24. Vague terms like “history of” or “status post” no longer support risk adjustment without evidence of active treatment or monitoring.
What Counts as Valid Documentation?
Valid documentation must include:
- Explicit diagnosis statements using acceptable terminology
- Evidence of evaluation, such as test results, imaging, or clinical findings
- Treatment plans addressing the documented condition
- Severity indicators were applicable for staged conditions
- Provider assessment and clinical judgment supporting the diagnosis
Common Documentation Gaps
Many practices find that documentation habits acceptable under V24 do not meet V28 standards. The most common issue is carrying forward previous diagnoses without reassessment
| Documentation Gap | V28 Impact | Solution |
| Missing severity staging | Reduced risk score | Implement structured templates with severity prompts |
| Incomplete mental health documentation | Lost HCC opportunities | Integrate mental health screening into primary care |
| Absent complication linkage | Lower payment weights | Use clinical decision support tools |
| Overlooked substance use disorders | Underfunded care needs | Train providers on new HCC categories |
| Historical diagnoses without reassessment | Non-qualifying conditions | Require annual condition validation |
Provider Education Needs
Physicians and clinical staff require targeted training on V28 documentation standards. Many providers lack awareness of how their charting directly affects patient care funding. Training priorities include:
- Recognition of newly mapped HCC conditions that were previously uncompensated
- Proper staging protocols for chronic diseases with severity levels
- Mental health screening and documentation for integrated care settings
- Annual condition reassessment to maintain valid risk adjustment
- Use of clinical decision support tools that prompt complete documentation
Technology Solutions for V28 Compliance
Modern digital health platforms integrate Artificial Intelligence and Natural Language Processing to extract diagnosis information from unstructured clinical notes. AI technologies detect documentation patterns that human coders may miss. They flag undocumented HCC opportunities using test results and medication lists.
Role of AI and NLP in Risk Adjustment
AI-powered systems analyze provider narratives to identify:
- Undocumented HCC opportunities based on test results or medication lists
- Incomplete severity staging for conditions requiring specificity
- Inconsistencies between problem lists and visit documentation
- Historical diagnoses requiring annual recapture under V28 rules
Persivia CareSpace® aggregates clinical data from EHRs, lab systems, and claims to build comprehensive patient profiles. The platform’s NLP engine processes unstructured notes, identifying conditions that meet V28 documentation standards and presenting providers with side-by-side views of V24 and V28 opportunities.
Benefits of Integrated Platforms
Multi-vendor environments create gaps where clinical information fails to flow between systems. Patients see specialists who document important conditions, but primary care teams never receive those updates.
Integrated solutions eliminate these disconnects by:
- Centralizing patient data from all care settings in a single view
- Automating risk score calculations as new documentation enters the system
- Tracking documentation completeness across the care team
- Providing retrospective and prospective HCC opportunities simultaneously
- Ensuring consistency when updating conditions across multiple systems
Preparing Health Plans for 2026
The V28 risk adjustment implementation requires months of planning within the clinical, coding, and technology units. By delaying until 2026, there will be an inadequate time to educate the providers and modify the system. It is important that organizations take immediate action to implement impact analysis, determine who was impacted, and create cross-functional teams.
What Should Plans Do Now?
Immediate action steps include:
- Conduct an impact analysis comparing current risk scores under V24 versus projected V28 scores
- Identify member populations most affected by coefficient changes
- Map ICD-10 codes currently used to their V28 HCC category assignments
- Assess technology readiness for handling new data requirements
- Develop provider engagement strategies that emphasize documentation improvement
Building Cross-Functional Teams
V28 success requires coordination between departments that traditionally work in silos. Clinical quality, coding, provider relations, and IT must align around shared goals.
Effective teams include:
- Medical directors who understand clinical care patterns and provider workflows
- Coding experts familiar with V28 mapping and documentation requirements
- Data analysts capable of modeling financial impacts and tracking progress
- Provider network management to deploy education and support programs
- Technology staff managing EHR integrations and decision support tools
Testing and Validation Processes
Plans should run parallel coding exercises using actual patient charts to compare V24 and V28 results. This testing reveals which member segments face the largest payment adjustments. Validation activities include:
- Sample chart reviews with dual coding under both models
- Risk score variance analysis identifying unexpected changes
- Provider feedback sessions discussing documentation challenges
- Technology testing with pilot provider groups before full rollout
- Appeals process preparation for disputed diagnoses or documentation
Addressing Health Equity Concerns
Patients facing barriers to routine care may have their severity underrepresented in the model, affecting risk scores and funding. Patients who face transportation difficulties, poor health literacy, or social determinants to healthcare services might have undertreated conditions that are not reflected in the risk scores. Plans involving a variety of populations should actively close documentation gaps, which are caused by social factors, as opposed to clinical realities.
How V28 Affects Vulnerable Populations
Health equity considerations include:
- Language barriers are preventing accurate symptom communication
- Cultural factors influencing healthcare-seeking behavior for mental health conditions
- Geographic isolation limits access to specialists who document complex conditions
- Economic instability is causing gaps in care where conditions progress undocumented
- Technology access is affecting telehealth participation for ongoing monitoring
Strategies for Equitable Implementation
Equity-focused approaches include:
- Community health worker programs that facilitate care access for isolated members
- Language-concordant providers and interpretation services during clinical encounters
- Home-based assessment programs reaching members unable to travel for appointments
- Partnerships with community organizations addressing social determinants of health
- Culturally adapted engagement recognizing different health belief systems
Common Implementation Challenges
Organizations report struggles with provider resistance, technology limitations, and resource constraints. The shift creates operational friction across multiple touchpoints in the care and claims process. Frequent challenges include:
- Provider skepticism about documentation requirements is perceived as an administrative burden
- The legacy system limitations are unable to flag V28 opportunities in real-time
- Insufficient coding staff to review charts comprehensively before submission
- Time pressure during patient visits is limiting documentation thoroughness
- Conflicting priorities between quality metrics and risk adjustment accuracy
Solutions That Work
Organizations successfully navigating V28 preparation share common strategies:
- Embed documentation prompts directly in EHR workflows that providers already use
- Provide real-time feedback during encounters rather than retrospective chart review
- Offer specific documentation templates that satisfy V28 requirements efficiently
- Create financial incentives tied to documentation improvement metrics
- Demonstrate the care impact of accurate documentation rather than focusing on payment
Wrap Up
CMS-HCC Model V28 represents healthcare’s most significant risk adjustment update in nearly a decade. The model is useful where the high-risk populations have the care complexity that is mirrored adequately, but only when the conditions are recorded with the specificity needed by V28. With the V28 implementation in 2026 approaching, health plans must upgrade systems, train clinicians, and test workflows promptly.
Persivia simplifies V28 risk adjustment with intelligent automation and seamless integration. CareSpace® aggregates data from EHRs, labs, claims, and social determinants to create complete patient profiles and highlight V24 and V28 documentation opportunities in real time.
Further, CareTrak® ensures bidirectional data flow, updating problem lists and risk scores automatically. Embedded V28 guidance fits into existing workflows, promoting accurate documentation without disrupting patient care. Persivia’s integrated approach overcomes operational challenges across multi-vendor systems, improving transparency and efficiency.
FAQs
Q1: Does V28 change patient care or just documentation?
V28 does not change clinical care protocols. It requires providers to document existing care and condition severity more thoroughly. Accurate documentation ensures appropriate care coordination and resource allocation for high-risk patients.
Q2: Will high-risk patients receive more services under V28?
Potentially, yes. When conditions are documented accurately, V28’s refined categories for mental health, substance use disorders, and advanced chronic diseases help direct additional funding toward comprehensive care management programs for these populations.
Q3: Can providers still use V24 codes after 2026?
No, starting in 2026, CMS will only accept V28 HCC mappings for payment. Outdated ICD-10 codes from V24 will no longer contribute to risk scores.
Q4: Does V28 require new EMR software?
Not necessarily. Existing EMRs can be updated to support V28-compliant documentation. Organizations must configure workflows, implement updates, and train providers on the new documentation requirements.
Q5: Are there penalties for incomplete V28 documentation?
There are no direct penalties. However, incomplete documentation leads to lower risk scores and reduced capitation payments, which can impact the resources available for high-risk patients.
