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The company also serves several international markets, and contracts with other healthcare and commercial organizations to provide a variety of specialty services focused on treating the whole person.
Error Rate Calculation Methodology
HCC Grouping for Failure Rate Calculation
HHS proposes to modify the creation of RADV HCC failure rate groupings and place all HCCs that share an HCC coefficient estimation group in the adult risk adjustment models into the same HCC failure rate grouping before determining failure rate of HCCs and HCC groups. These HCC failure rate groupings would be known as "Super HCCs." HHS will not apply a priori stability or hierarchy violation constraints, but seeks comments on whether its application is necessary.
"Payment Cliff" Effect
HHS proposes to calculate and apply a sliding scale adjustment between the 90 and 99.7 percent confidence interval bounds (from +/- 1.645 to 3 standard deviations) to mitigate the impact of the "payment cliff" effect.
Negative Error Rate Issuers with Negative Failure Rates
HHS proposes to adopt an approach that constrains negative error rate outlier issuers' error rate calculations in cases when an issuer's failure rate is negative. The approach intends to do so by applying a constraint to the Group Adjustment Factor (GAF) and calculating the negative error rate outlier as the difference between the weighted mean failure rate for the HCC grouping (if positive) and zero (0), beginning with the 2019 benefit year RADV.
Application of HHS-RADV Results
HHS proposes to transition from the current prospective application of RADV results to an approach that would apply the results to the benefit year being audited beginning with the 2021 benefit year. HHS proposes the following two approaches to accomplish a transition to the concurrent approach - (1) "average error rate" approach where HHS would calculate an average value for the 2021 and 2020 benefit years' RADV error rates and apply this average error rate to 2021 risk adjustment plan liability risk scores and transfers; or (2) "combined plan liability risk score" approach where HHS would apply 2020 benefit year RADV risk score adjustments to 2021 benefit year plan liability risk scores, and then apply 2021 benefit year RADV risk score adjustments to the adjusted 2021 plan liability risk scores. Alternatively, due to COVID-19, HHS seeks comment on whether to apply either of the outlined transition approaches to the 2020 benefit year RADV. The alternative timeline would require the 2020 benefit year risk adjustment plan liability risk scores and transfers to be adjusted twice - first to reflect 2019 benefit year RADV results and again based on 2020 benefit year RADV results.
We would be happy to share our analysis with HHS and work with other stakeholders to further discuss the proposed amendments to the RADV program that allow issuers to more effectively achieve the full potential of the program as envisioned by HHS and to mitigate any negative impacts on market stability.
Thank you for the opportunity to submit comments on this proposed rule. We remain committed to the
If you have questions or need more information, please contact me at [email protected] or 314.349.3086.
Vice President, Health Policy
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0059-0001
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