Risk Adjustment (RA) FAQ
Guidance for FAQ regarding Risk Adjustment Operations and Policy
Program Area: Risk Adjustment (RA)
Question: Are the business rules for the Medicare Risk Adjustment (RA) program the same as the HHS RA program that is in place for commercial health insurance?
Answer: The Medicare RA model provided the diagnostic framework for the Patient Protection and Affordable Care Act (PPACA) HHS RA model. However, the Medicare RA program and the PPACA RA program are distinctly different. Business rules for the HHS RA program are in place to meet CMS' Distributed Data Collection (DDC) requirements for the HHS RA state payment transfer methodology, neither of which (distributed data and state payment transfers) are concepts for the Medicare RA program. CMS has customized the HHS RA methodology and business rules to best mitigate adverse selection in the commercial health insurance individual and small group markets. For additional information DDC has published the Business Rules document locate here https://www.regtap.info/reg_library.php in the REGTAP library.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 22, 2019
HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
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.