Aug 13, 2018
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Proposed Rule for Permanent Risk Adjustment Program for 2018

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A new Centers for Medicare & Medicaid Services  (CMS) Press release details the proposed additional rule to address risk adjustment program for the 2018 benefit year.  The rule would give payers the ability to receive 2018 risk adjustment payments by resolving legal contentions of the program’s operation and give CMS the ability to issue risk adjustment payments without interruptions for the current plan year. According to reports the risk adjustment payments also reimburse health insurers who sell individual or small-group policies both inside and outside the Affordable Care Act’s (ACA’s) health insurance exchange.  Reports state that CMS officials believe the new draft regulations could affect about $4.8 billion in 2018 ACA risk-adjustment program payments. 

Excerpt from release:

On February 28, 2018, the United States District Court for the District of New Mexico issued a decision vacating/invalidating the use of statewide average premium in the HHS-operated risk adjustment methodology for the 2014 – 2018 benefit years. The government requested the court reconsider its decision and is currently awaiting the court’s ruling.

This CMS proposed rule further explains the justification for utilizing statewide average premium in the calculation of risk adjustment transfers, and expands on the reasoning behind operating the HHS-operated risk adjustment program in a budget-neutral manner. CMS seeks comment on the proposal to use statewide average premium in the risk adjustment methodology for the 2018 benefit year.

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