CMS proposed changes to the Medicare Advantage risk adjustment model

Late last month, the Centers for Medicare and Medicaid Services (CMS) released a 60-day “Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for the Medicare Advantage (MA) CMS-HCC Risk Adjustment Model,” which describes proposed changes to the 2019 Part C risk adjustment model. CMS is seeking comments on the proposed changes, which are […]

Managing ACA risk adjustment

Many issuers participating in the Patient Protection and Affordable Care Act (ACA) have not put in sufficient effort to create a deliberate, comprehensive risk adjustment strategy. That could lead to lost opportunities and less certain financial outcomes. The most successful risk adjustment management programs tend to be planned, firm-wide initiatives that recognize and account for […]

How does risk adjustment affect CMS episode-based payment models?

Each episode-based payment model has its own specific set of risk arrangements for providers to consider. Risk adjustment or risk stratification is present in these alternative payment models to amend payment levels and reflect cost considerations outside a provider’s control. In this paper, Milliman’s Samuel Bennett and Tom Snook provide a high-level guide on risk […]

Implication of coding on risk adjustment and valued-based contracting

Healthcare providers are measured on certain performance metrics that dictate their payment amounts under value-based contracts. Risk adjustment plays an integral role in determining financial performance. In order for these contracts to be equitable for insurers and providers, risk adjustment must accurately capture changes in population morbidity to effectively measure the provider’s true cost impact. […]

Risk adjustment modifications in view of potential CSR subsidy termination

If the cost-sharing reduction (CSR) subsidies of the Patient Protection and Affordable Care Act (ACA) were eliminated, it could expose insurance carriers to a substantial increase in selection risk related to their particular mixes of business. In August, the Centers for Medicare and Medicaid Services (CMS) announced its intention to propose a set of risk […]

Pairing risk adjustment to support state 1332 waiver activities

Section 1332 of the Patient Protection and Affordable Care Act (ACA) allows states, starting in 2017, to waive certain ACA market rules to allow for more tailored commercial individual and small group market solutions. When states consider market reforms such as reinsurance under the 1332 Waiver with the aim of stabilizing the market and providing […]