Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: October 28, 2014

Program Area: Risk Corridors (RC)

Question: The guidelines for Risk Adjustment and Reinsurance program are specific regarding the calculation of costs from capitated providers (i.e., indicating the submission of priced encountered claims) and guidelines for the Medical Loss Ratio (MLR) program are specific about the use of capitation payments (i.e., including the actual amount of capitation payment to these providers). How will capitated providers be handled in Risk Corridors' calculations and should issuers submit the priced encountered claims or the actual capitation paid to capitated providers?

Answer: In determining the amount of allowable costs to report for the risk corridors calculations, issuers should treat capitated provider payments in the same manner that these payments are treated for purposes of the MLR calculation.

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