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Last week, The Centers for Medicare and Medicaid Services (CMS) confirmed the risk adjustment program for the 2018 benefit year. The rule finalized the risk adjustment procedure previously established for the 2018 benefit year, permitting health plans offering coverage in the Affordable Care Act (ACA) marketplace to receive funds through the program.  

Here’s what you need to know: 

  • CMS suspended payments earlier this year because of the federal court case over payments. 
  • In February, the federal court of New Mexico overturned the use of statewide average premium in the risk adjustment process, passing it back to the lower court.  
  • The rule re-released Friday permits funds to be reorganized for the 2018 benefit year. No amount was released from CMS pertaining to funding. 
  • Health insurance companies that insure higher-risk patients in the ACA receive federal funds to alleviate the higher costs from other plans that cover lower-risk beneficiaries. The new risk adjustment program is considerably neutral.  
  • CMS’s re-releasing of the rule lets plans offer coverage without snowballing premiums to cover higher expenses.  

Fast Facts: New CMS Risk Adjustment Ruling for 2018

CMS reports in Friday’s press release, “with the Risk Adjustment program in place, premiums can reflect differences in scope of coverage and other plan factors, not differences in the underlying health status of enrollees.  This helps ensure that consumers have access to a robust array of affordable coverage options and encourages insurers to price competitively, rather than overly cautiously.”  

The final rule can be seen here:



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