ACA Now

Implementation Status

CCIIO’s page regarding premium stabilization programs links to relevant regulations and guidance, as well as fact sheets and FAQs.

2012

On March 23, 2012, HHS issued a final rule on standards relating to reinsurance, risk corridors and risk adjustment. Also see the accompanying fact sheet.

A May 1, 2012, bulletin on the risk adjustment program contains HHS’s proposed operations when operating risk adjustment functions on a State’s behalf.

2013

On March 11, 2013, HHS published a final rule – the Notice of Benefit and Payment Parameters for 2014 –addressing  the “Three R” premium stabilization programs (risk adjustment, reinsurance and risk corridors), among other topics. Also see an accompanying fact sheet.

Concurrently, CCIIO released an interim final rule with comment period (comments due on April 30) that builds on the final Notice. CCIIO posted a slide deck with an overview of the Notice and the IRF.

On May 7, CCIIO posted HHS-Developed Risk Adjustment Model Algorithm Software (for a ZIP of the SAS file, click here), including instructions for the 2014 benefit year, as well as technical details (Excel file). Sample datasets are available under the “guidance” section of CCIIO’s premium stabilization tab; see here. On May 29, HHS published a Federal Register Notice announcing a public stakeholder meeting regarding the HHS-operated risk adjustment data validation process; the meeting will be held on Tuesday, June 25 from 9:30 a.m. to 2 p.m. EDT.

On May 14, CCIIO released FAQs on Health Insurance Marketplaces addressing issues involving: (1) CMS oversight of state-operated premium stabilization programs, advance payments of the premium tax credit and cost-sharing reductions; (2) issuer oversight in Federally Facilitated Marketplaces; (3) State-Based Marketplace reporting requirements; (4) privacy and security standards for State-Based Marketplaces and consumer assistance personnel; (5) cost-sharing reductions and health savings accounts; (6) eligibility and enrollment – specifically, CMS’s intent to “propose rulemaking and supplemental guidance on the use of [Health Plan Identifiers] in enrollment and payment transactions between issuers and the Federally Facilitated Marketplace”; and (7) issuer withdrawal from the small group or large group market.

On May 24, CMS posted a Paperwork Reduction Act Notice regarding data collection and reporting for reinsurance, risk corridors and risk adjustment.

On June 22, CMS released – via the REGTAP site (registration required) – a white paper on the ACA’s HHS-Operated Risk Adjustment Data Validation Process. CMS had previously announced a stakeholder meeting on this topic, held at CMS headquarters in Baltimore on June 25.

On September 18, CMS sent a proposed rule to OMB for review relating to “Program Integrity: Exchange, SHOP, Premium Stabilization Programs, and Market Standards,” including wide-ranging provisions, including those relating to the risk adjustment, risk corridors and reinsurance, as well as advance payments of the premium tax credit and cost-sharing reductions, among other issues.

On September 24, CMS sent the CY 2015 Notice of Benefit and Payment Parameters proposed rule to OMB for review, noting the “proposed and subsequent final rule must precede plan approval and open enrollment (must be complete by January 1, 2014).” The proposed rule is anticipated sometime in October.

On October 24, CMS released a final rule (see a CCIIO fact sheet) codifying certain program integrity-related components of the ACA pertaining to Exchanges, premium stabilization programs and market standards that were delineated in a June 2013 proposed rule. The final rule also amends and adopts as final provisions delineated in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 interim final rule with comment issued in March 2013 related to risk corridors and reconciliation of cost-sharing.

On Nov. 1, CMS published a Notice requesting comments by Dec. 31, 2013, on an information collection (see #3 on p. 2) – “Initial Plan Data Collection to Support Qualified Health Plan (QHP) Certification and Other Financial Management and Exchange Operations” – relating to revisions to data elements collected from Qualified Health Plans to support various regulatory requirements. The agency notes that “based on experience with the first year of data collection, we propose revisions to data elements being collected and the burden estimates for years two and three.” Accompanying documents are available in a Paperwork Reduction Act Package.

On Nov. 6, CMS re-posted June 2013 guidance on the inclusion of supplemental diagnosis codes for computation of plan enrollee risk scores in cases in which HHS is administering the ACA risk adjustment process for states.

On Nov. 25, HHS issued a proposed rule establishing the CY 2015 benefit and payment parameters for the cost-sharing reductions (including the annual limitation on cost-sharing for stand-alone dental plans), advance premium tax credit, reinsurance, and risk adjustment programs as required by the ACA.  In addition, the proposed rule establishes the user fees for the Federally-facilitated Exchanges (FFEs), the annual open enrollment period for 2015, the actuarial value (AV) calculator, and other key provisions as required by the law.  Note that the rule allows for adjustments to the risk corridors and other premium stabilization programs in 2014 to account for the “transitional policy” (see the Nov. 14 CCIIO letter to Insurance Commissioners) that addressed plan cancellations, which could equate to broader risk corridors and thus higher stabilization payments to plans. Comments are due by Dec. 26, 2013.

2014

On Feb. 24, HHS sent the final CY 2015 Notice of Benefit and Payment Parameters rule to OMB for review, the final step before issuance of the regulation. It addresses ’15 parameters for ACA premium stabilization programs, as well as advance premium tax credits and cost-sharing reductions.

On March 5, CCIIO issued the 2015 Notice of Benefits and Payment Parameters final rule (fact sheet). Among other provisions, it includes a “state-level adjustment in the risk corridors formula to account for the transitional policy’s [on canceled plans] effect on the expected 2014 risk pool in a way such that the program is projected to be budget neutral, with payments in equaling payments out, while helping to ensure that prices remain affordable in 2015 and beyond,” according to the agency. The rule also finalizes the 2015 benefit year open enrollment as Nov. 15, 2014, through Feb. 15, 2015 (versus the proposed January 15, 2015 end date).  On March 14, CCIIO posted a proposed rule on Marketplace and broader insurance market standards for “2015 and beyond.” Among other changes, CCIIO proposes “changing the limit on allowable administrative costs to 22 percent [from 20 percent] and the limit on profits to 5 percent [a 2 percentage point increase] in the risk corridors calculation, in recognition of the ongoing uncertainty and changes in the market in 2015,” adding that the agency “expect[s] to implement this change in a budget neutral way” and that the adjustment would be “applied uniformly in all States for 2015 to help additional transition costs and uncertainty.” Comments on the proposed rule are due on April 21.

On April 21, 2014, CMS posted an overview of its Registration for Technical Assistance Portal, where FAQs and other information on Marketplace operations and ACA premium stabilization programs are available.

On April 11, 2014 CCIIO issued guidance on ACA risk corridors’ budget neutrality, saying it expects the program’s collections to be sufficient to make all payments but laying out an approach if collections fall short in a given year. CCIIO indicates that “if risk corridors collections are insufficient to make risk corridors payments for a year, all risk corridors payments for that year will be reduced pro rata to the extent of any shortfall.” Collections for the following year would first be applied to “pay off the payment reductions issuers experienced in the previous year in a proportional manner, up to the point where issuers are reimbursed in full for the previous year, and will then be used to fund current year payments.”

On April 14, in an FAQ, CMS said it does not have a cross-walk comparing Marketplace and Medicare risk adjustment and data validation, although “the two programs adopt similar methods regarding the sampling concepts and methods that require implementation of national acceptable standards for review of enrollee health conditions to validate payment accuracy.” That said, the agency distinguishes the two in that payment transfer is not a “payment concept” in Medicare Advantage.

On May 16, 2014 CCIIO released a final rule on Marketplace and insurance market standards for “2015 and beyond,” (fact sheet; blog post) addressing prescription drug exception standards; risk corridor and medical loss ratio adjustments; SHOP Marketplaces’ implementation of employee choice; the use of standardized notices for coverage renewal or product discontinuation; and other issues.

On May 16, 2014, CMS published an information collection notice (see #3 on p. 2) proposing revisions to a currently approved collection. Under it, the agency estimates a total of 15.6 million responses annually from 2,520 respondents. Comments are due by June 16, 2014. Further details on these information collections underlying the premium stabilization programs are provided in a Paperwork Reduction Act package supporting statement here.

On June 26, 2014, in slides discussing on-premise EDGE servers for enabling distributed data collection, CMS provides an overview of infrastructure, configuration, server, security and other issues for third-party administrators, support vendors, and insurance issuers weighing “which EDGE server option is the best fit for them.” On June 19, CMS posted slides providing technical guidance on file formats for issuers’ loading of data onto a distributed data environment to enable ACA risk adjustment and reinsurance. On May 27, CCIIO posted EDGE server details, including business rules, for risk adjustment and reinsurance.

On June 3, 2014, CCIIO posted instructions, updating a May 2013 version, for HHS’s 2014 benefit year risk adjustment models. The agency also posted technical details (Excel document) and an SAS Version of HHS-developed risk adjustment model algorithm software (ZIP file).

On June 18, 2014, the House Oversight and Government Reform Subcommittee on Economic Growth, Job Creation and Regulatory Affairs held a hearing with witnesses that included a lead CCIIO official, as well as appropriations lawmakers and legal and actuarial scholars, regarding the ACA premium stabilization programs.

On July 30, 2014 CMS published a notice requesting OMB’s emergency review of proposed changes to a currently OMB-approved information collection. The agency says “as a result of contractor changes and technical design changes to our distributed data collection (DDC) approach for implementing the risk adjustment and reinsurance programs, we must change the data elements that issuers will submit as part of the DDC information collection requirements,” adding that “these modifications will permit us to register EDGE servers with the appropriate issuer accounts, permitting CMS to make risk adjustment and reinsurance payments to issuers.” Comments are due by Aug. 27 2014.

On August 26, CCIIO issued a guide providing an overview of setting up an Amazon EDGE Server account for distributed data collection under ACA reinsurance and risk adjustment programs, as well as a separate document with guidance to insurers pre-configuring an on-premise EDGE server. On August 12, CCIIO released version 3.0 of thebusiness rules guide for EDGE Server data submission. The agency discusses file processing rules for specified types of claims files and diagnosis codes. On August 7, CCIIO posted slides reviewing key deadlines for distributed data collection processes.

On Sept. 5, a series of articles in the Medicare and Medicaid Research Review provide an overview of the “context and challenges” of the ACA risk adjustment program, including “key choices in how the methodology responds to these issues” (here). Subsequent articles address the HCC risk adjustment model itself (here) and the risk transfer formula (here).

On Oct. 21, in a final step before formal publication in the Federal Register, CCIIO sent the proposed rule on “CY 2016 payment parameters for the cost-sharing reductions, advance payments of the premium tax credit, reinsurance, and risk adjustment programs as required by the Affordable Care Act” to OMB for final approval.

On Oct. 24, CMS posted a table that summarizes updates to EDGE server functionality, a component of distributed data collection for risk adjustment. On Oct. 21, the agency posted an EDGE Server Operations and Maintenance Manual. On Sept. 29, as part of a video series, CMS reviewed details of file processing with Amazon EDGE servers for ACA risk adjustment. The technical assistance video (transcript) discusses the file upload process, a component of distributed data collection.

On Nov. 12, CMS released slides presenting key aspects of the ACA risk adjustment program’s methodology, including calculating risk scores and calculating plan payments and charges.

On Nov. 14, CMS posted FAQs (e.g., here and here) on its Registration for Technical Assistance Portal addressing EDGE Servers for data collection. On Nov. 10, HHS released a recap of key technical assistance issues in implementing EDGE servers.

On Jan. 13, 2015, CCIIO posted a weekly update on distributed data collection through EDGE Servers addressing “common schema tables and expected rows” and reinsurance calculation logistics, among other topics. Also see a Jan. 27, 2015, weekly update and set of release notes (REGTAP account required) as well as a Dec. 12 edition of the weekly update. On Dec. 19, as detailed here, CMS delayed the deadline for issuers to submit the first EDGE server production file until Dec. 28. This followed another extension of the original Dec. 5 deadline announced earlier in the month.

On Jan. 14, 2015, CCIIO posted FAQs (here and here; REGTAP account required) on risk score aggregation and the monthly schedule for running risk score calculations. Also see additional FAQs issued on Dec. 11 here and here.

On Feb. 2, CMS posted a weekly update on EDGE server implementation. On Feb. 19, announced that in response to issuer requests, it would run another risk adjustment and reinsurance calculation on Feb. 23; it also provided guidance for those with unsuccessful Feb. 12 runs and a Feb. 27 software upgrades.

On Feb. 20, CMS finalized the wide-ranging final 2016 Notice of Benefit and Payment Parameters rule that addresses – among other topics – ACA premium stabilization, Marketplace open enrollment and user fee, rate review, essential health benefits, prescription drug coverage and other issues generally affecting Qualified Health Plans (QHPs) for the 2016 benefit year. Also see a fact sheet. Additionally, on Feb. 20, CCIIO finalized the 2016 letter to health insurance issuers in the Federally Facilitated Marketplace, which addresses QHP certification timelines, benefit design, essential community providers, network adequacy and other issues.

On Mar. 4, CMS said that having released a software upgrade for EDGE servers, it now plans to run the latest ACA reinsurance and risk adjustment calculations on Mar. 10 instead of on Mar. 5. Also on Mar. 4, the agency posted FAQs QHPs’ registration with Pay.gov (here); access to the Marketplace and Premium Stabilization Programs Payment Form (here); and process for completing the form (here). In a Mar. 24 FAQ, CMS clarified that QHPs may use the rendering provider ID as the billing provider ID if the latter is not available.

On Mar.11, CMS posted FAQs explaining that ACA risk adjustment “payments and charges within a market and risk pool should net to zero” (here) and briefly summarizing the process for collecting payments and administering transfers among plans (here).

On Apr. 27, CCIIO posted a bulletin affording a “grace period for issuers to submit and update EDGE server data for the 2014 benefit year financial transfers through Friday, May 15, 2015, 4:00 p.m. EDT”; such data otherwise was due Apr. 30. CCIIO indicated the grace period would “not delay CMS’ transmission of risk adjustment and reinsurance results to issuers by Jun. 30, 2015.”

On May 8, CCIIO posted slides reviewing the steps involved in computing ACA reinsurance payments based on EDGE server data (slide 6). On May 20, CCIIO issued guidance explaining the formal discrepancy reporting procedures that apply to outbound EDGE server risk adjustment and reinsurance estimate reports.

On June 1, GAO released a report, “Despite Some Delays, CMS Has Made Progress Implementing Programs to Limit Health Insurer Risk.”

On June 5, CCIIO posted a log of updates to EDGE server processes. On June 30, CCIIO released a report on 2014 benefit year reinsurance payments and risk adjustment transfers by insurance issuer. Also see a press release and details on issuers’ administrative appeals processes.

On July 7, CMS released a technical correction to its 2016 Notice of Benefit and Payment Parameters final rule.

On Sept. 2, CMS posted an FAQ confirming that the 2015 EDGE server registration and provisioning process is the same as 2014.

On Sept. 18, CCIIO updated its June 30 report on ACA reinsurance payments and risk adjustment transfers for the 2014 benefit year to account for additional and corrected data since the original release.

On Sept. 2, CCIIO issued guidance explaining its approach to addressing adjustments to 2014 risk adjustment transfers in the event that an insurer submitted “materially incorrect” data. The agency intends to codify its approach in the 2017 Notice of Benefit and Payment Parameters regulatory cycle.

On Sept. 15, on ICD-10, CMS clarified that the “HHS-operated Risk Adjustment Program remains unchanged and follows current clinical coding guidelines that require an accurate diagnosis accompanied by a valid code,” adding that the 1-year period of “claims payment leniency for ICD-10 codes” applies only to fee-for-service Medicare claims from physicians and other practitioners.

On Dec. 17, CCIIO posted FAQs on the parameters for QHPs’ inclusion of telehealth services in ACA risk adjustment data submission (here) and 2015 Benefit Year HHS-Operated Risk Adjustment Data Validation key dates (here).

2016

On Jan. 11, 2016, CCIIO posted an FAQ indicating that it plans to publicly post interim ACA risk adjustment data in March 2016 to assist QHPs with 2017 rates. It will be based on preliminary data submitted by Feb. 1 that meets the agency’s sufficiency thresholds. 

On Jan. 20, 2016, CCIIO released guidance explaining how it will assess QHPs’ submission of EDGE server submissions for ACA risk adjustment and reinsurance interim reports during the 2015 benefit year.

On Jan. 26, CMS said it will host a March 31 conference on ACA risk adjustment, including methodological changes in 2018 and beyond.

On Feb. 12, CMS posted an FAQ discussing its non-enforcement policies for ACA risk adjustment data validation requirements that apply to specified plans for the 2015 benefit year.

On Feb. 22, as a resource to QHPs, CMS posted a timeline with milestones in ACA risk adjustment between the beginning of 2016 and winter 2017.

On Feb. 23, in remarks at a conference, CMS Acting Administrator Andy Slavitt said that the agency would release a white paper on ACA risk adjustment in advance of its March 31 public meeting on the topic.

On May 5, CMS released a guide for QHPs addressing the attestation and discrepancy reporting process for ACA risk adjustment and reinsurance for the 2015 benefit year.

In May 11 slides, CMS noted the extended deadline (to May 31) for QHPs to submit a CEO-signed attestation form and provided a timeline of risk adjustment data validation processes.

On May 23, CMS posted an FAQ discussing the status of risk adjustment administrative appeals and plans for releasing a 10 percent hold-back of 2014 benefit year payments once such appeals are resolved in states in which they remain pending.

On June 6, as part of its announcement of risk adjustment refinements, CMS released a series of FAQs on anticipated upcoming proposed changes, adjustments for partial-year enrollment, inclusion of prescription drug data, and other issues.

On June 8, CMS posted an FAQ indicating that “QHPs may submit 99 diagnosis codes on a supplemental record; however, there is no limit to the number of supplemental records that can be submitted for an individual medical claim.”

On June 9, CMS posted an FAQ explaining when sequestered ACA risk adjustment payments will become available to QHPs, including the timing implications of any pending appeals.

On June 30, CMS released a summary report conveying preliminary estimates of overall and issuer-specific risk adjustment payments and transfers, as well as reinsurance payments, for the 2015 benefit year.

On July 18, CMS posted updated protocols for use in Benefit Year 2015 HHS-Operated ACA Risk Adjustment Data Validation.

On July 27, in a 104-slide presentation, CMS outlined the process for the initial validation audit, which addresses “demographics and enrollment, claims data, and medical record validation,” the agency notes.

On July 29, CMS posted a compendium of public comments received on its March 2016 discussion paper, which addressed potential modifications to the ACA risk adjustment program.

On July 22, CMS transmitted the Calendar Year 2018 Notice of Benefit and Payment Parameters proposed rule to OMB for regulatory review, marking a final step before the proposal is issued for public comment through the Federal Register.

On Aug. 24, CMS updated its 72-slide presentation on ACA risk adjustment validation audit procedures, which addresses initial data validation audits, timelines, necessary documentation and records, and related issues.

On Aug. 26, CMS posted the latest details on 2016 data submission through EDGE servers, including current implementation status and technical specifications.

On Aug. 29, CCIIO released the Calendar Year (CY) 2018 Notice of Benefit and Payment Parameters (NBPP) proposed rule (TRP Health Policy summary). CMS makes proposals in a range of areas, including network breadth, essential community providers, ACA risk adjustment, standardized plan options, and more. Comments are due in 30 days.

On Aug. 30, CMS released slides describing its web-based process for QHPs’ reporting on the status of their EDGE servers for 2016 benefit year data submission.

On Nov. 7, CMS posted the protocols for 2015 benefit year ACA risk adjustment data validation. The 91-page document provides an overview of the process, explains the selection of initial audit entities, and discusses the audit tool and sampling process, among other aspects.

On Nov. 8, CMS highlighted updated protocols for 2015 benefit year ACA risk adjustment data validation. The agency notes 10 specific changes made to improve the clarity of its procedures.

On Nov. 16, CMS extended the deadline for QHPs to submit results under the ACA risk adjustment data validation (RADV) initial validation audit (IVA). The deadline for the pilot being conducted for the 2015 benefit year, which had been Dec. 1, now is Dec. 30, 2016. The agency will accept IVA results between Nov. 21 and Dec. 30. Also see an updated timeline.

On Nov. 18, CCIIO posted a key dates chart that highlights, on p. 3, milestones for the 2016 benefit year ACA reinsurance and risk adjustment programs.

On Nov. 28, in an interactive training session, CMS provides QHP issuers with an overview of the file submission tool through which they submit packages for ACA risk adjustment data validation.

On Dec. 6, 2016, CCIIO issued an adjusted report on 2015 benefit year ACA transitional reinsurance and permanent risk adjustment payments and charges.

On Dec. 16, 2016, CMS released the Calendar Year (CY) 2018 Notice of Benefit and Payment Parameters final rule. The wide-ranging annual Exchange rule addresses ACA risk adjustment and an array of policies affecting QHPs.

2017

On April 13, CMS released slides on the ACA risk adjustment data validation audit tool beginning on slide 8. The agency discusses key steps for the audit tool’s registration process, which opens on April 14.

On April 27, CCIIO posted the 2018 benefit year final HHS risk adjustment model coefficients (see here) and child and infant model coefficients (see Excel file here).

On May 9, CCIIO announced that the form used in ACA risk adjustment and reinsurance attestation and discrepancy reporting is now available here.

On May 11, CMS released a guide for QHPs on ACA reinsurance and risk adjustment attestation and discrepancy reporting, including how to use the web-based form to attest and report any applicable discrepancies.

On June 30, CMS released a report, “Summary on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2016 Benefit Year.” It found that “both the transitional reinsurance program and the permanent risk adjustment program are working as intended in compensating plans that enrolled higher-risk individuals, thereby protecting issuers against adverse selection within a market within a state and supporting them in offering products that serve all types of consumers.”

In Aug. 10 guidance, CCIIO outlined changes it intends to propose in future rulemaking on risk adjustment to account for potential loss of cost-sharing subsidies but said “there have been no changes regarding HHS’ ability to make cost-sharing payments to issuers” at this time.

On Sept. 18, CMS said it is allowing an additional 30 days (new deadline: Feb. 7, 2018) for insurers in Texas, Florida, and Georgia affected by Hurricanes Harvey and Irma to provide HHS-operated Risk Adjustment Data Validation Initial Validation Audit (IVA) documentation.

On Sept. 21, CMS transmitted the Calendar Year 2019 Notice of Benefit and Payment Parameters proposed rule to OMB for regulatory clearance, a final step before the rule is released for public comment.

2018

On April 9, CMS released the calendar year 2019 Notice of Benefit and Payment Parameters (NBPP) final rule as well as the 2019 Letter to Issuers in the Federally-facilitated Exchanges and guidance on the unified rate review timeline for the 2018 filing year. The agency also extended its transitional plan guidance for one year.

On July 7, CMS announced it is barred from making $10.4 billion in 2017 benefit year payments to individual and small group plans under the ACA’s permanent risk adjustment program due to a U.S. District Court ruling.

On July 24, CMS released a final rule reissuing its existing 2017 benefit year ACA risk adjustment methodology with additional explanation of its rationale, allowing agency to restore $10.4 billion in risk adjustment collections and payments for the 2017 benefit year in the individual and small group markets.

On Aug. 8, CMS issued a proposed rule which proposes to adopt the risk adjustment methodology previously established for the 2018 benefit year of the Affordable Care Act’s (ACA) Risk Adjustment Program.

2019

On Jan. 17, CMS released the awaited calendar year 2020 Notice of Benefit and Payment Parameters proposed rule, which includes proposals affecting the individual and small group insurance markets, including Exchanges.

On April 18, CMS released the CY 2020 Notice of Benefit and Payment Parameters final rule.

On Dec. 9, CCIIO released a white paper on its error estimation methodology for risk adjustment data validation (RADV).