Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: November 18, 2014

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: Section 7.2, Table 41 of the EDGE Server Business Rules (ESBR), version 2.0, states claims from 'both inside and outside the marketplace' are accepted. Can the Centers for Medicare & Medicaid Services (CMS) elaborate on what this means?

Answer: In general, issuers with non-grandfathered plans in the individual or small group market, both inside and outside the Marketplace will need to be included in EDGE server data submissions. However, only plans that are subject to the 2014 market reform rules are required to submit data for the Risk Adjustment (RA) and Reinsurance (RI) programs. Grandfathered or transitions plans are excluded from the risk adjustment and reinsurance programs. Please refer to the 2014 Payment Notice for more information on the plans that are required to participate in the RA and RI programs.

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