Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server FAQ
Guidance for FAQ regarding Edge Server Operations and Policy
Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server
Question: For the transitional reinsurance program and permanent risk adjustment program, can an issuer submit claims costs or diagnosis for an enrollee who is admitted in the 2013 benefit year but discharged in the 2014 benefit year or who is admitted under a plan not subject to the market reforms rules but discharged under a plan subject to the market reform rules?
Answer: No. Pursuant to 45 CFR 153.234, a reinsurance-eligible plan's covered claims costs for an enrollee incurred prior to the application of the insurance market reforms at 147.102 (fair health insurance premiums), 147.104 (guaranteed availability of coverage, subject to the student health insurance provisions at 147.145), 147.106 (guaranteed renewability of coverage, subject to the student health insurance provisions at 147.145), 156.80 (single risk pool), and subpart B of part 156 (essential health benefits package) to that plan do not count towards the reinsurance payments parameters. Pursuant to the preamble to the HHS Notice of Benefit and Payment Parameters for 2014 (78 FR 15418), plans not subject to the market reform rules are treated separately, such that these plans would not be subject to risk adjustment charges and would not receive risk adjustment payments. Therefore, if an enrollee's date of admission is prior to January 1, 2014 or under a plan not subject to the market reform rules, then the claims costs incurred for this enrollee cannot count towards the attachment point for reinsurance payments, nor can the enrollee's diagnoses be used because plans not subject to market reforms are not subject to incurring risk adjustment charges or receiving risk adjustment payments.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: December 19, 2013
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