Risk Adjustment (RA) FAQ
Guidance for FAQ regarding Risk Adjustment Operations and Risk Scores
Program Area: Risk Adjustment (RA)
Question: If an enrollee is enrolled in two (2) different plans (in the same market) in a benefit year and receives a diagnosis for a condition under one plan, how would the Risk Adjustment algorithm calculate the enrollee's individual risk score?
Answer: For each enrollee ID, the Centers for Medicare & Medicaid Services (CMS) will use all risk adjustment eligible claims submitted from across all plans within the issuer to calculate a risk score for each of the enrollee's enrollment periods. This means that if the member changes plans within the same issuer, claims data from each plan will be utilized to calculate the member's plan-specific risk scores. Note: the risk score value could change based on CSR status or plan actuarial value. If the member changes issuers, even within the same insurance company, then the claims data used to calculate the risk scores will relate to each specific issuer only. CMS will not link enrollee data across different issuers.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 25, 2019
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