Medicare Advantage Actuarial Cost and Revenue Model
Interactive · client-side only Tables onlyScenario
Maintain three presets: Baseline, Conservative, Improved. All inputs below are saved per scenario.
Revenue inputs
Risk adjustment (CMS-HCC v24 / v28 blend)
Year weights default to CMS phase-in pattern: 2024 ≈ 0.67/0.33, 2025 ≈ 0.33/0.67, 2026 = 0/1. Quality bonus and rebate share vary by Stars; enter values used in your bid book.
Clinical RAF and HRA/CR conversion
Literature suggests only ~53–64% of incremental RAF from HRAs and chart reviews maps to spending (Jung et al., 2023; Carlin et al., 2024). This block produces an “effective clinical RAF” that drives utilization.
Medical cost model
Enter events per 1000 member-years and allowed dollars per event. Program effect adjusts utilization by service class.
| Service class | Events / 1000 / yr | Allowed per event ($) | Program effect on utilization (%) | PMPM ($) |
|---|---|---|---|---|
| Total medical cost PMPM | $0.00 | |||
Revenue results (per member per month)
| Benchmark adjusted for Stars | $0.00 |
| Blended normalized RAF (after 5.9% coding adj) | $0.000 |
| Risk-adjusted benchmark | $0.00 |
| Risk-adjusted bid | $0.00 |
| Rebate PMPM (if bid < benchmark) | $0.00 |
| Member premium PMPM (if bid > benchmark) | $0.00 |
| Total revenue PMPM (incl. member premium if selected) | $0.00 |
When bid ≤ benchmark, CMS pays risk-adjusted bid and a rebate share of the gap. When bid > benchmark, CMS pays risk-adjusted benchmark and the enrollee pays the difference as premium.
Net results
| Admin load (% of revenue) | 0.0% |
| Admin dollars PMPM | $0.00 |
| Medical loss ratio (claims / revenue) | 0.0% |
| Operating margin (% of revenue) | 0.0% |
Compare scenarios
| Metric | Baseline | Conservative | Improved |
|---|
Sources and notes
Show citations
- CMS (Apr 1, 2024). 2025 Rate Announcement (phase-in to v28, 5.9% coding pattern difference). PDF: cms.gov/files/document/2025-announcement.pdf
- CMS (Dec 2024). Report to Congress, Risk Adjustment in MA (v28 design, calibration, predictive ratios). cms.gov/…/report-congress-risk-adjustment…
- MedPAC (Mar 2025). Medicare Advantage status report (payment gap, selection, coding intensity). Chapter 11 PDF: medpac.gov/…/Mar25_Ch11…
- Carlin, Feldman, & Jung (2024). Coding intensity mechanics. HSR. Open access: pmc.ncbi.nlm.nih.gov/articles/PMC11063086
- Jung, Feldman, & Carlin (2023, corr. 2024). HRA/CR wedge vs spending. MCRR. journals.sagepub.com/doi/10.1177/10775587231191169
- JAMA Network Open (2024). Stars and county social vulnerability. pmc.ncbi.nlm.nih.gov/articles/PMC11267407
Implementation notes: This tool treats the Stars quality bonus as a multiplicative factor on the county benchmark and applies rebate percentages commonly used in practice. RAF blending follows a simple payment-weighted approach with normalization and a coding pattern offset applied multiplicatively. All are user-editable to match your official bid assumptions.