From Challenge to Opportunity: Understanding the Future of Medicare Advantage New 2025 CMS Requirements 

Key Changes in CMS HCC Model V28 

The V28 update introduces a paradigm shift in how risk is assessed, and in how payments are distributed. Notable changes include: 

1. Expanded Condition Categories: The model now includes 115 HCCs, an increase from 86 in V24, providing a more comprehensive classification system that captures a broader spectrum of clinical conditions. 
2. Updated Coding Priorities: Conditions that were previously grouped are now stratified, resulting in a more granular approach to risk adjustment. 
3. Elimination of Certain Diagnoses: CMS has removed over 2,000 ICD-10 codes, focusing on those with the most key predictive value for patient outcomes and costs. 
4. Greater Emphasis on Social Determinants of Health (SDOH): Acknowledging the impact of socioeconomic factors, CMS’s updates highlight the importance of addressing health equity. 
5. Phased Implementation: After a transitional period that began in 2023, the V28 updates allowed risk adjustment programs time for adaptation and are now fully implemented in 2025.  

Greater Good Health: Your Partner in Navigating V28 

Greater Good Health specializes in delivering solutions that empower healthcare organizations to adapt to regulatory changes while maintaining efficiency and effectiveness. Here’s how we can help:

Comprehensive Clinical Team with Training and Support

We provide in-depth training programs to ensure our providers are proficient in the updated HCC categories and understand the complexities of ICD-10 coding. Our Clinical Strategy and Operations teams pivot in real-time to create ongoing training programs that tightly follow legislative and regulatory changes.  

In addition, Greater Good Health’s robust Clinical Quality program includes clinical oversight and constant support for all its team members. We provide our clinicians with periodic clinical educational tips, highlighting these latest changes and findings, allowing our clinicians to apply these learnings in their future appointments.  We also perform weekly internal chart reviews on our clinicians to ensure we are supporting each visit from a documentation perspective but also to ensure we have appropriate clinical evidence for the conditions we are coding. This allows our NPs to have real time feedback and ensure its incorporated in their visits.   

Our experienced teams collaborate with clients to define patient prioritization logic and stratification to ensure resources are maximized. Thoughtful analytics and in-depth reporting create a flywheel effect, as learnings are built and leveraged for continuous improvement, year over year.

Seamless Care Coordination

Greater Good Health’s solutions prioritize minimal disruption and reducing provider abrasion, by streamlining workflows and minimizing administrative burden. Our services include proactive outreach for Annual Wellness Visits (AWVs), quality gap closures, medication review, care planning, hospital readmission prevention, and other key quality initiatives. No matter which clinical services are provided, continuity of care is of utmost importance so that patients are connected to the support they need. 

Expertise in Health Equity

CMS has introduced an increased focus on Social Determinants of Health via the Health Equity Index and the SDOH-1 and SDOH-2 screenings. Greater Good Health has long served the most medically complex and chronically underserved patients.  Our programs are designed and optimized to address disparities in care and improve health equity metrics. By doing the right thing for our patients, we have already closely aligned our programs with developing standards of health equity. In fact, one of our kidney care partners had organizational goals for their high-risk patients, including those with chronic conditions, complex medication regimens, caregiver needs, and social determinants of health. By addressing these factors, Greater Good Health helped improve care coordination and outcomes for this vulnerable CKD and ESRD population.  

Maximizing ROI

Greater Good Health understands our clients’ investment in external programs and has built a partnership model that has consistently reported significant ROI and measurable improvements in care quality and patient satisfaction.