Risk Adjustment (RA) FAQ
Guidance for FAQ regarding Risk Adjustment Operations and Software Code
Program Area: Risk Adjustment (RA)
Question: Should issuers continue to use the current risk adjustment score algorithm for internal scoring purposes, or will the Centers for Medicare & Medicaid Services (CMS) provide an updated algorithm?
Answer: Risk scores will be calculated using CMS developed software that will be run on the EDGE server. Issuers may utilize the April 6, 2018 HHS-Developed Risk Adjustment Model Algorithm Software (https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.html) to approximate their risk score for the applicable Benefit Year. The software is updated annually and is guidance for issuers to better understand and simulate the calculation of plan liability risk scores for their expected enrollees. It provides a simulation to calculate enrollees' risk scores and is not a requirement. Issuers should not use the software to filter claims to the EDGE server since the EDGE server software may have several additional layers of operational information.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 28, 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.