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CMS Proposed Rule Aims to Secure 2018 Risk Adjustment Payments

A CMS proposed rule would allow payers to receive 2018 risk adjustment payments by resolving legal contentions of the program’s operation.

CMS rule extends risk adjustment payments for plan year 2018

Source: Centers for Medicare and Medicaid Services

By Thomas Beaton

- CMS has proposed a new rule that aims to resolve legal issues over the risk adjustment program’s payment methodology.  The rule would ensure that payers will receive appropriate risk adjustment payments for plan year 2018.

The proposed rule will implement CMS’s statewide premium methodology to calculate payment rates and provides a clarifying statement on how the 2018 payments are issued.

On February 28, 2018, the US District Court of New Mexico issued a ruling that led to the suspension of the statewide premium to calculate risk adjustment payments.

CMS resolved the court’s legal contention in a final rule that more fully explains the methodology used to calculate payments.  However, the final rule only addressed the delivery of risk adjustment payments for the 2017 plan year, leaving uncertainty around payments for future years.

The proposed rule will allow CMS to issue risk adjustment payments without interruptions for the current plan year. CMS Administrator Seema Verma believes that the proposed rule allows the risk adjustment program to act as a stabilizing force within the nation’s health insurance markets.

“Today’s proposed rule continues our effort to help stabilize the individual and small group markets,” Verma said in a press release. “Our goal has been, and will continue to be, to stabilize the market and provide American consumers with more affordable health coverage options.”


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