Risk Corridors (RC) FAQ
Guidance for FAQ regarding Policy and Other
Program Area: Risk Corridors (RC)
Question: Can the Centers for Medicare & Medicaid Services (CMS) provide issuers with information on and examples of Risk Corridor eligible Qualified Health Plans (QHPs)?
Answer: Eligible QHPs that are subject to the Risk Corridors program are health plans offered outside the Exchange by an issuer of the same plan as a QHP, as defined by 155.20 of the Federal Registrar. In order to be the same plan as a QHP, the health plan offered outside the Exchange has identical benefits, premium, cost-sharing structure, provider network, and service area as the QHP. Consequently, an off-Exchange plan with a different service area from the QHP offered by the issuer on the Exchange, will not be considered the 'same plan' as an Exchange QHP, and will not be eligible for the Risk Corridors program. As defined in 45 CFR 153.500, a plan offered outside of the Exchange is substantially the same as an Exchange QHP, if it is the same as an Exchange QHP (according to the definition above), except for any variations in benefits and cost-sharing structure that are directly tied to Federal or State requirements or prohibitions on the coverage of benefits (for example, coverage of the Pediatric Dental Essential Health Benefit) that apply differently to plans depending on whether they are offered through the Exchange. Plans that are offered outside of the Exchange that meet the definition of a plan that is 'substantially the same' as an Exchange QHP are also eligible for the Risk Corridors program.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: February 02, 2015
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