Press release

CMS finalizes rule on the risk adjustment program for the 2018 benefit year

CMS finalizes rule on the risk adjustment program for the 2018 benefit year
Final rule sustains premiums and choice in the Exchange

Today, the Centers for Medicare & Medicaid Services (CMS) issued the final rule, “Patient Protection and Affordable Care Act; Methodology for the HHS-operated Permanent Risk Adjustment Program for 2018,” which reissues, with additional explanation, the HHS-operated risk adjustment methodology previously established for the 2018 benefit year. Issuing this rule allows CMS to continue normal operations of the Risk Adjustment program for the 2018 benefit year after a federal judge vacated the use of statewide average premium under the HHS methodology earlier this year.

“Today’s final rule continues our commitment to provide certainty regarding this important program, to give insurers the confidence they need to continue participating in the markets, and, ultimately, to guarantee that consumers have access to better coverage options,” says CMS Administrator Seema Verma. “Although the litigation is still pending, thanks to CMS’ clear commitment and ongoing steps to strengthen the markets, I am pleased to report insurer participation on HealthCare.gov increased for the 2019 benefit year, demonstrating improved confidence in the markets.”

On February 28, 2018, the United States District Court for the District of New Mexico issued a decision vacating the use of statewide average premium in the HHS-operated risk adjustment methodology for the 2014 – 2018 benefit years. Although the litigation is still pending, we are issuing this final rule to preserve the consistent, ongoing operation of the Risk Adjustment program for the 2018 benefit year.

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: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-26591.pdf.

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