RAF, MLR & MER
Master the three financial metrics that drive Belong's revenue, cost management, and performance measurement.
Risk Adjustment Factor (RAF)
RAF is a multiplier CMS uses to adjust capitation payments based on a member's predicted health costs. It's derived from demographic data and HCC (Hierarchical Condition Category) codes submitted via claims and encounter data.
Formula: Monthly Payment = Base Rate × RAF Score. A healthy 65-year-old might have RAF ~0.7; a complex dual-eligible with CHF + diabetes might be 2.5+.
RAF Revenue Simulator
$450/month | $5400/year
Low RAF — member is relatively healthy. Ensure all conditions are coded.
MLR & MER
Medical Loss Ratio (MLR) = Medical Claims / Premium Revenue. CMS requires MA plans to maintain 85%+ MLR.
Medical Expense Ratio (MER) is Belong's internal metric capturing total medical spend relative to capitation revenue.
Knowledge Check
Question 1 of 3
A member with RAF score 1.5 vs. 0.8 — what does this mean for revenue?
💡 Reflection: If a member's RAF drops from 1.8 to 1.2 due to poor documentation, what's the annual revenue impact at a $900 base rate?