HHS-Operated Risk Adjustment Data Validation – 2016 Benefit Year Implementation and Enforcement

The Centers for Medicare & Medicaid Services (CMS) released a memo stating that it would not hold plans accountable for not validating high-risk claims from 2016. The Affordable Care Act established a risk-adjustment program which provides financial aid to those insurers that cover individuals with complex health conditions.  The law mandated that auditors and the Department of Heath & Human Services  confirm that plans receiving risk-adjustment payments do indeed have sicker patients.
 
As a result, CMS will exempt from the 2016 benefit year small issuers with total premiums of $15 million or less, as of the May 1, 2017, EDGE data submission. In addition, CMS will not enforce participation in 2016 benefit year for insures that are not offering coverage in the 2017 benefit year. 
 
However, CMS will assess issuers’ performance in 2016 benefit year for efforts in medical record retrieval and good faith compliance. 

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