Risk Adjustment

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Policy Examples

  • In 2019, the Centers for Medicare and Medicaid Services (CMS) released new rules for what Affordable Care Act (ACA) insurers will receive or owe in response to complaints from payors. The purpose of the change is to increase accuracy of payments and collections. source
  • The Medicare Advantage (MA) risk adjustment payment model is adjusted annually. In 2020, the new rule proposed to CMS would incorporate 50 percent of the 2017 infrastructure and 50 percent of a new risk adjustment model. source
  • America’s Health Insurance Plans (AHIP) opposes initiatives by the CMS to lessen risk-adjustment payments for those offering MA plans, calling the new proposal “fundamentally unfair and ill-conceived”. source

Outcome Evidence

  • CMS released a report in review of the 2018 risk adjustment program, in which they included data detailing that the program “operated smoothly”. Because New Mexico and CMS are in litigation over the fairness of the risk adjustment program, reporting on the statistically measured merits of the program is important. source

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