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Risk Adjustment (RA) FAQ

Guidance for FAQ regarding Risk Adjustment Operations and Payments

Final

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

Issue Date: May 22, 2020

Program Area: Risk Adjustment (RA)

Question: How do the Centers for Medicare & Medicaid Services (CMS) determine my monthly Risk Adjustment (RA) transfer proration amount?

Answer: The monthly cycle of RA proration payments will only distribute funds that have been collected in your same risk pool/market. Issuers will only receive payments if CMS has collected an RA charge in your risk pool/market. Issuers will only receive a portion of their payment amount if RA transfer charges are not collected in full prior to the monthly payment cycle. Additionally, any payment amount will have sequestration applied, as applicable. Payments are made around the 20th of each month. RA Proration reports are sent by the end of each month for issuers who received transfer payments. The RA Proration report is made available on an issuer's External Data Gathering Environment (EDGE) Server Management Console.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.