Hierarchical Condition Category (HCC) Risk Scores: Designed to Predict Future Cost and Health Care Resource Use – Do They Also Accurately Reflect Differences in Health Status between Rural and Urban Beneficiaries?

The validity of the Centers for Medicare and Medicaid Services Hierarchical Condition Category (CMS-HCC) risk scores have been questioned based on observed regional and geographic differences in coding practices and varied diagnosis frequencies – indicating diagnoses may not directly relate to underlying health risk. With the growing use of CMS-HCC risk scores for other Medicare payment programs, including those impacting increasingly smaller groups of health service providers and rural populations, understanding the drivers of regional and geographic differences is vital. Accurately assessing risk promotes accountability and fairness in payment models and extend the utility of risk scores to additional aspects of care. This study investigated CMS-HCC risk scores between rural and urban beneficiaries using recent data and analyze which factors drive observed differences.

Publications

• Are HCC Risk Scores a Reliable Health Status Indicator Across Rural and Urban Areas?
  Policy Brief
  ETSU/NORC Rural Health Research Center
  Date: 04/2025
  This brief explores differences in CMS Hierarchical Condition Category (HCC) risk scores between rural and urban Medicare beneficiaries, revealing lower scores for rural populations despite higher chronic disease prevalence. The brief highlights HCC score limitations and suggests improvements and alternatives for accurate health representation.