The Model Output Report (MOR) is a pivotal resource that Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) use to understand how CMS interprets enrollee-level risk adjustment data. Created after the Model Output File (MOF), the MOR summarizes all the demographic and Hierarchical Condition Category (HCC) variables that were triggered for a beneficiary. These variables are essential for determining each enrollee’s Risk Adjustment Factor (RAF) score.

This report serves a dual purpose: supporting operational insight and enabling data validation. It ensures that health plans have visibility into how CMS interpreted their data submissions and provides transparency into the risk model output.

What Is the MOR?

The MOR provides a list of all the demographic and HCC model variables that are triggered for a particular beneficiary. This list forms the basis for the risk score that CMS calculates. For example, if an enrollee had diabetes or a chronic pulmonary condition, and it was submitted and accepted through CMS filtering, then those corresponding HCCs would be reflected in the MOR.

Two Main File Types:

Data File: Compact, flat file designed to be read positionally. Each position corresponds to a specific model variable (e.g., Male, Age 70–74, Diabetes without Complication, etc.). Each variable is represented by a 1 or 0, indicating whether it was triggered.

Report File: A more readable format designed for human review. It includes plan ID, HICN/MBI, contract number, and descriptive variable names for easy interpretation.

Both files provide the same underlying data but are designed for different uses. Larger plans may prefer the data file for integration into automated systems, while smaller plans may use the report version for manual review.

Who Receives Which Files? The type of MOR received depends on the plan’s structure:

MA Plans (Part C): Receive Part C MOR

PDP Plans (Part D): Receive Part D MOR

MA-PD Plans: Receive both Part C and Part D MORs

This segmentation ensures that each organization receives only the relevant data for their enrolled beneficiaries.

When Are MOR Files Sent? CMS provides MOR files at specific intervals throughout the year:

Monthly MOR: Generated from January to June using monthly payments. These files provide near real-time feedback on the data CMS is using for payment.

Final MOR: Sent after the Final Reconciliation payment year using final MOF data. This is the definitive source and should be used for final score validation.

Why the MOR Is Important: The MOR is CMS’s only official feedback to plans regarding the risk model output. Plans use it for a variety of critical tasks:

Validation: Ensures that internal risk adjustment logic aligns with CMS's interpretation.

Audit Preparation: Identifies which demographic and clinical variables were activated, helping plans build documentation.

HCC Identification: Highlights missing HCCs or unrecognized diagnoses.

Appeals: Offers data to support correction of risk scores through appeals.

Smaller plans may rely solely on the MOR for understanding their risk scores, while larger plans may compare MOR data to internally generated scores to catch inconsistencies.

What is Full Risk (FR) ? The concept of Full Risk (FR) applies to plans based on how long a beneficiary has been enrolled:

Continuing Enrollees: Members with 12 months of A/B coverage.

New Enrollees: Members with less than 12 months of continuous A/B.

Plans receive separate scores for new and continuing enrollees and can choose which group-level score to use. This flexibility is critical in aligning payment strategies.

Use Cases for the MOR

Coding Gap Analysis: Identify unrecognized conditions not included in the final model output.

Data Submission Review: Confirm what CMS has accepted and filtered from your submissions.

Provider Feedback: Use the MOR to give feedback to providers on the impact of their documentation.

MOR and RAF Scores The MOR aligns with the RAF scores CMS calculates. Every triggered variable in the MOR contributes to the final RAF score. Plans can cross-reference this data with their own risk scoring logic to ensure consistency.

Conclusion The Model Output Report (MOR) is an essential tool for Medicare Advantage and Prescription Drug Plans. By offering transparency into the variables used in risk score calculation, the MOR empowers plans to validate, audit, and refine their risk adjustment programs. Whether you're a large national plan or a small regional player, effectively using the MOR can make a significant difference in compliance, revenue accuracy, and operational excellence.

Understanding every element of the MOR and its generation process helps ensure that plans not only remain compliant but also optimize their risk adjustment performance in alignment with CMS guidelines.