The April 2026 CMS Payment Rules Will Reshape Risk Adjustment. Here's What Health Plans Need to Do Now.
Three regulatory developments now in effect for the 2026 plan year — the CY 2026 MA final rule CMS published on April 4, 2025, the related Rate Announcement that completed the V28 phase-in, and the parallel RADV enforcement push CMS escalated through 2025 and early 2026 — are not a one-year technical correction. Together, they signal that prospective vs retrospective risk adjustment is no longer a neutral choice. CMS now expects health plans to capture risk scores through accurate, clinically grounded documentation, not after-the-fact chart retrieval.
For plans still running retrospective-heavy risk adjustment programs, the math is changing. Administrative costs are rising, yield is declining, and audit exposure from retrospectively sourced diagnoses is increasing. Plans that treat the 2026 rules as a temporary disruption will spend the next several years catching up. Plans that treat them as the start of a new operating environment will build a compounding advantage.
Retrospective risk adjustment is not going to get cheaper or more complete. The question is how long a plan waits before building something better.
What the April 2026 Rules Actually Changed
The 2026 final rule introduces three changes that matter most for risk adjustment strategy.
First, the updated HCC model (V28 refinements) recalibrates the relative payment weights for a range of chronic conditions. Some conditions that carried significant RAF weight under prior models now carry less, while others are better valued. Plans that built their risk adjustment programs around legacy code targets will need to reprioritize.
Second, the statutory coding intensity adjustment — roughly 5.9% in 2026, with MedPAC estimating an effective impact closer to 7% when measured against FFS — continues to apply. CMS has also signaled in the 2027 Advance Notice that further changes targeting unlinked chart review diagnoses are coming. The practical effect is sustained downward pressure on RAF scores, with the greatest impact on plans that lack complete, high-quality clinical documentation.
Third, CMS has dramatically accelerated Risk Adjustment Data Validation (RADV) auditing through a separate track. This includes the January 27, 2026 RADV update committing to quarterly audits across all eligible MA contracts, the March 20, 2026 PY 2020 audit methods guidance, and the unresolved extrapolation question following the September 2025 Humana v. Becerra decision currently on appeal. Together, these developments narrow the standard for what counts as a defensible diagnosis. A note from a chart review conducted months after the encounter is no longer sufficient on its own. A diagnosis must be supported by clinical documentation created during a care encounter within the measurement year.
Retrospective chart reviews that surface diagnoses outside of documented care encounters sit directly in this risk zone.
Plans that built their risk adjustment programs around retrospective chart retrieval are now operating against a tightening set of standards on all three dimensions.
Why Prospective vs Retrospective Risk Adjustment Is No Longer Equal
Retrospective risk adjustment has always had a structural flaw: it asks providers to respond to administrative requests after the care relationship has moved on. A chart chase initiated six months after a patient encounter does not document a clinical finding. It attempts to reconstruct one.
This creates several compounding operational and financial issues.
Provider offices handle large volumes of medical record requests. Response rates vary, turnaround times stretch, and the quality of documentation retrieved is inconsistent. Plans often pay per-chart fees to vendors to manage this volume, and the cost per closed HCC gap through retrospective channels is typically materially higher than the cost of a prospective closure.
The completeness ceiling is also inherent. Retrospective programs can only find what was documented. If a provider did not address a relevant chronic condition during a visit, a chart review cannot manufacture that documentation. The gap remains open. The RAF opportunity is lost for the plan year.
Under the 2026 RADV framework, there is now an additional dimension. Even when retrospective reviews find supporting documentation, the risk of that documentation failing audit scrutiny is higher than it has been historically. CMS reviewers are trained to assess whether diagnoses were evaluated and treated, not just mentioned in a record. A diagnosis that appears in a retrospective note without clinical context is a liability, not an asset.
What Prospective Risk Adjustment Makes Possible
In a prospective vs retrospective risk adjustment model, the difference comes down to timing and control. Prospective risk adjustment starts with the same information that drives a retrospective program — member-level data, prior-year HCC codes, claims history, and care gap registries — but applies that information before the care encounter, not after it.
The workflow is straightforward: analytics identify members with unconfirmed or potentially underdocumented chronic conditions. Those insights reach providers ahead of scheduled visits. The provider reviews the member’s history, evaluates the relevant condition during the encounter, and documents their clinical assessment. The diagnosis is captured in real time during a care visit, with clinical context that makes it defensible in audit.
The difference in economics is significant. Prospective programs typically achieve lower cost per HCC closure than retrospective chart chases, because the marginal cost of adding a structured clinical prompt to a scheduled encounter is far lower than the marginal cost of requesting, retrieving, and reviewing a medical record after the fact.
The difference in completeness is structural. Prospective programs work across the full provider network throughout the plan year, giving plans multiple opportunities to close each gap before the measurement window closes. Retrospective programs are bounded by what was documented. Prospective programs can influence what gets documented.
*Prospective programs can influence what gets documented. Retrospective programs cannot. *
The Long-Term Strategic Implications
Plans that invest in prospective risk adjustment infrastructure now will build advantages that extend well beyond the 2026 plan year.
RAF score accuracy compounds. A plan that closes 80 percent of its HCC gaps in 2026 enters 2027 with a more accurate baseline, better-calibrated outreach lists, and a provider network already accustomed to the documentation workflow. A plan that closes 50 percent of its gaps retrospectively enters 2027 starting over.
Provider relationships improve. Prospective programs that deliver structured, clinical useful information build goodwill that retrospective chart chase programs consistently erode. Providers receiving a clear, relevant prompt ahead of a scheduled visit are more likely to engage than those receiving a records request three months after the fact.
Audit exposure shrinks. Diagnoses captured through prospective encounters carry stronger clinical documentation than those surfaced through retrospective review. As RADV audits intensify, this difference in documentation translates directly into reduced financial risk.
Star Rating performance strengthens. Risk adjustment accuracy and care gap closure are not separate programs. When providers are engaged prospectively on chronic condition documentation, they are also more likely to complete the quality measures that drive Star Ratings. The underlying infrastructure overlaps.
How Veradigm Supports the Shift
Veradigm Payer Insights gives health plans the analytics to run a prospective program at scale. It surfaces HCC gap opportunities across the full provider network in near real time, stratified by impact and member care status, so risk adjustment teams can prioritize outreach rather than build lists manually.
eChart Courier provides data retrieval infrastructure to close those gaps. Rather than sending chart requests, plans send structured clinical prompts to providers ahead of scheduled visits. Providers respond within their existing EHR workflow. Documentation is captured during care, and sent directly to payers for review and closure.
Together, as components of the Veradigm Core Payer Platform, these capabilities give plans the closed-loop infrastructure to operate a prospective program throughout the measurement year, not just as a sprint before the close.
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