What Is a RAF Score?
RAF scores sit at the center of risk-adjusted payment in Medicare Advantage, ACOs, and other value-based care programs. This guide explains what a RAF score means, how it is calculated, what a "good" RAF score is, and why it matters in healthcare.
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Key data points
- An average-risk Medicare beneficiary has a RAF score of exactly 1.0 — the CMS normalization baseline.
- CMS phases in the CMS-HCC V28 model over three payment years: PY2024 = 67% V24 / 33% V28, PY2025 = 33% / 67%, PY2026 = 100% V28.
- A RAF score is recalculated every calendar year; chronic conditions must be re-documented annually to keep counting.
Source: CMS CY2024 Medicare Advantage and Part D Rate Announcement.
Worked example (our RAF V24 vs V28 tool): for one patient profile the same diagnoses scored RAF 3.001 → $28,105.86 under CMS-HCC V24 versus RAF 3.079 → $32,028.81 under V28 — a delta of +0.078 RAF / +$3,922.95 (about 14% higher MA payment for this profile). The identical conditions remapped from V24 HCCs 106/136/18/85 to V28 HCCs 226/263/326/37/38, which is why the direction is population-specific and must be modeled, not assumed. Single illustrative patient — not an average.
RAF Score Meaning
RAF stands for Risk Adjustment Factor. The "risk" being measured is financial risk — specifically, how much a given patient is expected to cost to care for over a year compared with a typical Medicare beneficiary. CMS uses the RAF score to adjust the fixed (capitated) payments it makes to Medicare Advantage plans and accountable care organizations so that organizations caring for sicker, more complex populations receive proportionally higher payment.
In plain terms: the RAF score answers the question, "How sick and complex is this patient, and what does that imply about their expected cost of care?" A healthy 70-year-old with no chronic conditions will have a low RAF score. A patient with diabetes, congestive heart failure, and chronic kidney disease will have a substantially higher RAF score because their documented conditions predict higher spending.
RAF score definition (CMS): in the CMS risk adjustment program, the CMS RAF score is the beneficiary-level multiplier — built from demographics plus HCC-coded conditions — that CMS applies to the base payment for a Medicare member. So when people ask "what are RAF scores" or "what is a RAF score in healthcare", the short answer is the same: a RAF score is CMS's standardized measure of how costly a patient is expected to be, used to pay health plans and risk-bearing providers fairly for the patients they actually manage.
How Is a RAF Score Calculated?
A RAF score is calculated by adding together a series of risk coefficients drawn from the CMS-HCC risk adjustment model:
RAF = Demographic coefficients + Disease (HCC) coefficients + Interaction terms → adjusted by normalization and coding pattern factors
Each ICD-10 diagnosis code documented for the patient during the calendar year is mapped to a Hierarchical Condition Category (HCC). Each HCC carries a coefficient (a risk weight). Demographic attributes — age, sex, Medicaid/dual eligibility, disability status, and whether the patient is institutionalized — carry their own coefficients. Certain combinations of conditions (for example, diabetes plus chronic kidney disease) add extra "interaction" weight because they compound cost. The model then applies a normalization factor and a coding-pattern adjustment so scores remain comparable year over year.
Because the mapping from diagnosis codes to HCCs is detailed and changes between model versions, most organizations use a RAF Score Calculator rather than computing scores by hand.
Components of a RAF Score
1. Demographic factors
Age and sex bands, original reason for entitlement (disability), Medicaid/dual-eligible status, and community vs. institutional residence. New enrollees use a separate demographic-only model because no diagnosis history is available yet.
2. Health status (HCCs)
Documented chronic conditions, grouped into HCCs via the ICD-10 to HCC crosswalk. HCCs are hierarchical: within a clinical family, only the most severe (highest-weighted) category counts, so less severe related codes do not double-count.
3. Interaction terms
Add-on weights for clinically significant condition combinations that predict disproportionately higher cost.
RAF Score Example
Consider a 74-year-old female, community-dwelling, not dual-eligible, with documented type 2 diabetes with chronic kidney disease and congestive heart failure:
| Factor | Contribution (illustrative) |
|---|---|
| Demographic (female, 74, community, non-dual) | ~0.323 |
| HCC — Diabetes with chronic complications | ~0.166 |
| HCC — Congestive heart failure | ~0.331 |
| HCC — Chronic kidney disease | ~0.127 |
| Disease interaction (diabetes + CKD) | ~0.121 |
| Total RAF score (approximate) | ~1.068 |
Coefficients above are illustrative and vary by model version and payment year. Use the RAF Score Calculator for exact values, and the RAF V24 vs V28 comparison tool to see how the same patient scores under each model.
What Is a Good RAF Score?
There is no single "good" RAF score, and a higher RAF score is not inherently better. A RAF score of 1.0 represents an average-risk beneficiary. The right RAF score is the one that accurately and completely reflects the patient's documented conditions for the calendar year — supported by medical record evidence that meets MEAT criteria (Monitored, Evaluated, Assessed, Treated).
Under-documentation understates risk and underpays the organization for genuinely complex patients; inflating scores without clinical support is non-compliant and a RADV-audit risk. The goal is documentation accuracy, not score maximization.
RAF Score Range: Average vs. Good RAF Score
A RAF score has no fixed maximum, but in practice most community Medicare Advantage members fall within a predictable band. The reference points below are illustrative — exact figures depend on the model version, payment year, and population:
| RAF score range | What it typically indicates |
|---|---|
| Below ~0.7 | Younger or healthy member with few or no documented chronic conditions |
| ~0.9 – 1.1 | Around the average RAF score — 1.0 is the CMS normalization baseline |
| ~1.2 – 2.0 | Multiple managed chronic conditions (e.g., diabetes, CHF, COPD) |
| Above ~2.0 | High-acuity / complex member, often with condition interactions or institutional status |
This is why "what is a good RAF score" and "what is the average RAF score" have the same answer: the right RAF score is the one that accurately reflects the member's documented conditions for the year. A panel-level average RAF meaningfully below the population's true acuity usually signals under-capture, not a healthier panel. For a one-page reference of the factors and ranges, see the RAF score cheat sheet.
Why RAF Scores Matter in Healthcare
RAF scores are foundational to value-based care. They determine risk-adjusted revenue for Medicare Advantage plans and ACOs, drive accurate budgeting and benchmarking, support population health management by surfacing the highest-need patients, and underpin compliant documentation programs. For provider organizations taking on financial risk, RAF accuracy directly affects both reimbursement and the ability to fund care for complex patients.
RAF Score Models: V24 vs V28
The same patient can have a slightly different RAF score depending on which CMS-HCC model version applies, because CMS is moving from model V24 to V28. That is a model-transition topic rather than a definitional one — the full mechanics, timeline, and impact are covered in the CMS-HCC V28 guide, and the V24 vs V28 comparison shows both scores side by side.
Calculate a RAF score in seconds
Enter ICD-10 codes and get an instant, model-accurate RAF score with HCC mapping.
Open the RAF Score CalculatorFrequently Asked Questions
RAF stands for Risk Adjustment Factor — a numeric score CMS assigns to a Medicare beneficiary representing their predicted cost of care relative to an average beneficiary (whose RAF is 1.0).
There is no universally "good" RAF score. 1.0 is average risk. An accurate RAF score is one that fully and correctly reflects the patient's documented chronic conditions for the year — not the highest possible number.
It is the sum of demographic coefficients plus HCC disease coefficients (mapped from ICD-10 codes) plus interaction terms, then adjusted by a normalization factor and coding pattern adjustment.
Yes. RAF scores recalculate each calendar year. Chronic conditions must be documented and coded at least once every calendar year to keep contributing to the score.
HCCs are clinical groupings of ICD-10 codes; the RAF score is the final risk number. Each HCC carries a coefficient that feeds the RAF score. See HCC and RAF explained.
In healthcare, a RAF score is the risk-adjustment number CMS uses to predict a patient's relative cost of care. It standardizes how Medicare Advantage plans and risk-bearing providers are paid so organizations caring for sicker patients receive proportionally more.
The average RAF score is 1.0 by definition — the CMS normalization baseline. Most community members fall roughly between 0.7 and 2.0, with higher-acuity patients above 2.0. The accurate score, not a target number, is what matters.
The CMS RAF score is the official Risk Adjustment Factor produced by the CMS-HCC model: demographic coefficients plus HCC disease coefficients (from ICD-10 codes) plus interactions, normalized so 1.0 is average. It is most often used in Medicare Advantage.
Where a RAF score goes wrong
- Under-capture: documented-but-uncoded chronic conditions never reach the score — HCCs reset every calendar year.
- Over-capture: diagnoses without MEAT-level record support invite RADV recoupment.
- Model mismatch: comparing scores across V24 and V28 without accounting for the model year misleads.
- Target thinking: the accurate score, not the highest one, is the goal.
General compliance guidance; confirm specifics against the current CMS Rate Announcement and your organization's policy.
This page is educational and does not constitute coding, billing, legal, or clinical advice. RAF coefficients and CMS-HCC model rules change by payment year; always confirm against the current CMS Rate Announcement and your organization's compliance guidance. CPT® is a registered trademark of the American Medical Association; HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). This page is independent and is not affiliated with, endorsed by, or sponsored by CMS, the AMA, or NCQA.