With Medicare serving as a precedent, many additional risk adjustment initiatives have been increasingly following suit. The Medicaid landscape is rapidly adopting a risk adjusted reimbursement model in nature or entirety. With this, accurately assessing and representing the comprehensive encounter, diagnostic, procedural, and pharmaceutical characteristics of enrollees has become paramount to those plans dependent on appropriate reimbursement. Regardless of the underlying risk adjustment factor determinant toolset – whether HCC, CRG, ACG, CDPS, DCGs, or other model – the requirement of accurate assessment, improvement, and reporting of factors that drive risk score calculation is critical. Failure to do so has both significant quality of care implications and critical financial ramifications.While there are many similarities between the state Medicaid risk adjustment models, each program has variances. The impact of under-documented patients, non-users of the program, and chronic care patients all have significant cost implications to these Medicaid programs. Further still, is the importance that many programs of Medicaid (unlike the Medicare risk adjustment programs) do not provide for retrospective correction or reimbursement for prior periods. For this reason, it is often critical for health plans subject to Medicaid risk adjustment to be proactive, or else they will be subject to reimbursement rates that they have had no impact.