Medicare’s New Health Insurance Market Place Rules – Impact on Risk Adjustment/HCC Coding

by | Published on Dec 27, 2016 | Medical Billing

Health Insurance
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The Centers for Medicare and Medicare (CMS) has released new health insurance market place rules which will take effect from January 17, 2017. Referred to as the “payment notice,” the rule is an annual CMS omnibus rule that covers all the major changes that CMS plans to implement during the next year for the marketplaces, including the federally facilitated exchange (FFE) and federally facilitated Small Business Health Options Program (SHOP) Marketplace. Medical billing companies have taken note of the changes in final rule, according to a Health Affairs report, is focused on strengthening and improving the marketplaces. The rule will impact the MRA/HCC Coding for 2017 and 2018.

The main areas that Medicare’s final rule addresses are as follows:

  • Modifications to the ACA’s general market reforms – changes to the five-year ban on market reentry upon withdrawal of an insurer from a market, child age rating, and transitions to Medicare, and changes in the medical loss ratio rules to assist new and rapidly growing plans.
  • Changes in the risk adjustment program for 2017 and 2018.
  • The 2018 payment parameters (the FFE user fee, premium adjustment percentage, and annual limits on cost sharing).
  • Changes in plan benefits (bronze plan changes, gold and silver plan participation requirements, standardized options, and essential community provider and network requirements).
  • Eligibility, enrollment and other changes (requirements affecting special enrollment periods, language access, direct enrollment, web-brokers, binder payments, insurance affordability programs, and SHOP participation, and a requirement that insurers make qualified health plans (QHPs) available for the entire year).
  • Strengthening marketplace oversight (including new rules governing insurer rescissions, civil money penalties, and decertifications and appeals).
  • Final changes to the rules governing special enrollment periods and the CO-OPs.

Beginning in 2017, CMS’ proposed policies will take important steps to strengthen the risk adjustment program, which is one of the Marketplace’s key tools for protecting consumers’ access to high-quality, affordable coverage options. The risk adjustment program is aimed at removing incentives for insurers to provide coverage only for those with lower medical risk factors. Key changes to the risk adjustment program for the next two years are:

  • Modifications to the risk adjustment program in 2017 to better measure the cost of enrollees who drop their coverage before the plan year is over
  • Use of drug utilization data starting in 2018 to give payers a better idea of the costs involved with insuring certain enrollees
  • Spreading the cost of the most expensive enrollees among insurers
  • Greater emphasis on demographic variables as compared to medical condition variables to estimate the adult risk adjustment model

HCCs use risk adjustment factors (RAFs) to capture complex health conditions. CMS uses risk adjustment diagnosis codes and demographic data reported for one year to determine payment for the next year based on patient risk scores. Success with HCC coding depends on accurate, specific, and complete diagnosis documentation. Physicians can ensure more accurate coding of chronic conditions and improve their risk adjustment factor scores in 2017 and beyond with the help of medical coding services.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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