Frequently Asked Question (FAQ)


FAQ ID:  14740a Publish Date: 04/20/2016
* Retired FAQ
Retired Date:  04/15/2019

* Retired FAQ - FAQ for which policy may have changed or been updated. FAQ is available for informational purposes only in order to provide historical program knowledge. Not intended to provide current guidance or policy.

Program Area:

HHS Risk Adjustment Data Validation (HHS-RADV)

Primary Category:

General Audit Standards (IVA-SVA)

Secondary Category:

IVA

Question:

Do all issuers of risk adjustment covered plans need to hire an Initial Validation Audit (IVA) entity for purposes of 2015 HHS Risk Adjustment Data Validation (HHS-RADV)?

Answer:

Given that 2015 HHS-RADV is a 'pilot year' and audit results will not adjust issuers' payments, CMS will not enforce the 2015 HHS-RADV requirements for:

(1) issuers that have no risk adjustment covered plans in the individual and small group markets in the 2016 benefit year; and

(2) issuers with 12,000 or fewer billable member months in the individual and small group markets combined statewide as of the April 1, 2016 data submission deadline for 2015 benefit year risk adjustment.

CMS has determined that issuers with 12,000 or fewer billable member months have a disproportionately higher administrative burden to participate in the pilot year of HHS-RADV and thus, CMS will not enforce participation for issuers with 12,000 or fewer billable member months in 2015 HHS-RADV. We note that issuers who previously met the criteria as of the February 2, 2016 data submission and received letters from CMS that we would not enforce participation, continue to not be required to participate in 2015 HHS-RADV.


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