The multi-year transition from the CMS HCC V22 to the HCC V28 risk adjustment model is no small shift. For PACE organizations, this change brings significant operational and financial adjustments. To help programs prepare (without losing too much sleep), IntusCare recently hosted the webinar “Decoding PACE risk adjustment in the HCC v28 era.”
Our experts, Melissa Bolish, RN, CRC (Director of Risk Adjustment), and Henning Chiv, FSA, MAAA (Director of Analytics), broke down the complex risk adjustment process (which becomes even more complicated with v28) and provided some actionable takeaways. If you missed the session, don’t worry, we’ve got some of the highlights for you here. And you can access and watch the full recording here.
What’s changing: V22 vs. V28
At its core, the move from V22 to V28 is about greater clinical specificity. Translation: “close enough” coding won’t cut it.
Alongside this, programs are transitioning from the legacy RAPS system to the more comprehensive EDS system for data submission. The official goal? Reduce over-coding and improve accuracy.
To make it real, the team introduced a fictional participant—Jared—whose risk scores were calculated under both models.
Under V22, his score came from three components:
- Demographics
- Specific diagnoses
- Triggered disease interactions
V28 adds a fourth piece: the HCC Count, which rewards specificity for participants with multiple qualifying HCCs.
The adds, the drops, and the plot twists
All PACE leaders are asking which HCCs stay, which go, and are there any additions?
HCC’s being removed:
- Protein-Calorie Malnutrition
- Mild and Unspecified Depression
- Certain Immunodeficiencies
- PVD without complications
HCCs being added:
- Dementia
- CKD Stage 3
- Personality Disorders
- End-Stage Heart Failure
As Malissa explained, the additions of highly prevalent conditions like dementia and CKD Stage 3 should soften the blow of losing others like PVD. The moral of the story? Specificity pays. Vague or unspecified documentation, especially for conditions like depression, will no longer risk-adjust.
The financial reality check
At first glance, raw risk scores might look like they’re dipping under V28. But Henning’s financial deep dive showed why it’s not that simple. Several external factors come into play, including normalization, coding, and frailty adjustments.
One key highlight: frailty scores are expected to rise under V28, thanks to the ADL mix in the PACE population. Even bigger news? County-level rates are projected to increase by an average of 10.7% nationwide in 2026.
Back to our friend Jared: despite a dip in his raw risk score, he still came out ahead, more than $600 in additional monthly revenue; largely thanks to those county rate increases.
Check out the book rates at: https://www.cms.gov/files/zip/2026-ma-rate-book.zip
What PACE organizations should do now
The session wrapped with a checklist for getting ahead of the curve:
- Train your teams: Providers and coders need to double down on clinical specificity.
- Get EDS-ready: Ensure systems and workflows are ready for timely, compliant submissions.
- Tighten documentation: Medicare Advantage-level scrutiny is coming. Every diagnosis must be backed up.
- Run your numbers: Model the impact of V28 on your own population and revenue.
Bottom line: the V28 transition is big, but manageable, especially if you plan now instead of playing catch-up later.
Simplify your V28 transition with IRIS
Change doesn’t have to mean chaos. The Intus Revenue Integrity System (IRIS) was built to help PACE programs manage the V22-to-V28 shift without losing revenue (or sanity).
Here’s how IRIS makes the transition smoother:
- Manage both models: Surface conditions for both V22 and V28 during the blended period.
- Empower providers: AI + expert clinical validation delivers pre-encounter insights right into provider workflows.
- Stay compliant: Every diagnosis is reviewed by a certified consultant—so you’re audit-ready, always.
- Get expert support: A dedicated risk adjustment consultant + real-time analytics = less guesswork, more confidence.
Want to see IRIS in action? Schedule a demo and get a head start on V28 success.
Watch the webinar (and get a copy of the slides)
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