Risk Adjustment
Risk adjustment can be an effective mechanism for removing incentives for insurers to pick healthier potential members, and for spreading risk from potentially less healthy members across plans in the individual and small group markets.
*Milestone details:
*Full name: Develop a plan to adjust risk for qualified plans in the individual and small group markets inside and outside the exchange consistent with federal laws and regulations.
*Relevance to the ACA:
Beginning in 2014, the ACA requires states to risk adjust plans that offer coverage in the individual or small group market within the state, with the exception of grandfathered plans.
§1343 - Requires states in conjunction with the Secretary of HHS to establish criteria for risk adjustment and for the states to carry out the process of risk adjustment for plans in the individual and small group market. States will assess a charge on plans that have lower than the state’s average actuarial risk and make a payment to plans with actuarial risk higher than the state’s average.
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District of Columbia
During our exchange webinar, a user asked a question related to the federal risk adjustment model. See the question and answer here: http://www.statereforum.org/discussions/exchange-policy-decisions#commen...
District of Columbia
On November 30, 2012 HHS released a proposed rule that provides further detail on: the
risk adjustment, reinsurance, and risk corridors programs; cost-sharing reductions; user
fees for a Federally-facilitated Exchange; advance payments of the premium tax credit; a
Federally-facilitated Small Business Health Option Program; and the medical loss ratio
program.
District of Columbia
This brief from Health Affairs outlines what risk adjustment is, related provisions in the ACA and the issues in implementation.
District of Columbia
On May 1, 2012, CCIIO released a bulletin related to the risk adjustment and reinsurance program. The bulletin sets forth HHS' approach to implementing risk adjustment when HHS is operating the risk adjustment function on behalf of a state and seeks comment on that approach. This bulletin addresses issues such as payment transfer, data collection and validation and privacy and security.
Evalue8TM: Health plans provide detail on how they educate, engage and incent consumers to promote health and manage disease, as well as measure and pay providers. Plans and purchasers receive objective scores enabling comparison of plans against regional and national benchmarks and a roadmap for improvement. As a result of face-to-face discussion of findings and roadmap, health plans learn what they need to do to align their strategies with purchaser expectations to maximize the value
of the health care investment and ultimately, improve health and quality of care.
North Carolina
This brief, which summarizes a Commonwealth Fund–supported conference of leading risk adjustment experts, outlines the reform law’s risk adjustment provisions and analyzes the merits of different risk adjustment strategies. Among other recommendations, the brief suggests that regulators use diagnostic rather than only demographic risk measures, that they allow states some but limited flexibility to tailor risk adjustment methods to local circumstances, and that they phase in the use of risk transfer payments to give insurers more time to predict and understand the full effects of risk adjustment.
District of Columbia
These draft policy recommendations on an insurance Exchange were submitted to the OR Health Policy Board. Access the draft recommendations here: http://statereforum.org/sites/default/files/or_oha_expolicyrecs_081310_0...
District of Columbia
This draft document provides responses to OCIIO provisions regarding the Exchange. It includes comments on Exchange operations, qualified health plans, actuarial value, enrollment, IT systems, and risk adjustment. Access the comments here: http://www.statereforum.org/sites/default/files/colorado.pdf
District of Columbia
This report by the New York State Health Foundation details the challenges and opportunities NY faces in implementing reform, including Exchange, benefit design and payment issues. Access the report here: http://www.statereforum.org/sites/default/files/nyroadmappaper_aug2010.pdf
District of Columbia
This section of Utah Code creates a Risk Adjuster Board, that has the ability to set policies related to risk in the defined contribution market, which directly affects the Exchange. The board has a specific scope and does not oversee the Exchange.
Access the code here: http://le.utah.gov/UtahCode/section.jsp?code=31A-42
California
The document is MD's response to the HHS request for comments on insurance exchanges.
Access the comments here:
http://www.statereforum.org/sites/default/files/maryland_0.pdf
District of Columbia
These comments are California's response to the HHS request for comments on insurance exchanges. they include comments on Exchange issues, risk adjustment, eligibility and enrollment and more. Access the comments here:
http://www.statereforum.org/sites/default/files/california-1.pdf