Risk Adjustment (RA) FAQ
Guidance for FAQ regarding Risk Adjustment Operations and Policy
Program Area: Risk Adjustment (RA)
Question: Can the Centers for Medicare & Medicaid Services (CMS) clarify the definition of spouse in the context of billable member months and Allowable Rating Factor (ARF)?
Answer: The External Data Gathering Environment (EDGE) server enrollment file does not specifically identify the spouse on the subscriber's plan. The EDGE server RA software will derive the spouse based on the oldest non-subscriber greater than or equal to 18 years old. Any person designated as a spouse by the software is a billable member. In order to calculate ARF, the EDGE server uses all billable member months.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 25, 2019
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