Open Enrollment and Risk Adjustment

As for many who are in the depths of risk adjustment, you may be just coming up for air after a whirlwind of changes that were outlined in the Centers for Medicare & Medicaid Services (CMS) 2019 Final Call Letter, midyear adjustments, final reconciliations for 2016/2017, and the September sweep slated for September 14, 2018. Just when you thought the chaotic waters were calming down, we now get to leap head first into Open Enrollment, and some may ask, “Open Enrollment – Who Me? Captain Chaos of risk adjustment? How does Open Enrollment impact my already chaotic world?”

Well, my friends who all wear the super hero shirt of risk adjustment, let me give you a few tips. While you may not be directly involved with some of the processes, believe me, the downstream impacts can be great, so muscle up…

  • September 7: This will mark the threshold for your initial 2019 payment year (PY). Ensure your enrollment is current and reconciled, all claims with dates of service 7/1/2017 – 6/30/2018 are reported, and all changes, deletes, adds, etc., are in good shape.
  • September 14: The September sweep date – final PY 2016 reconciliation (encounter data and Risk Adjustment Processing System (RAPS) delete dates of service (DOS) 1/1/2015 – 12/31/2015), final 2017 reconciliation PY (encounter data and RAPS delete DOS 1/1/2016 – 12/31/2016).

Now that we are through September, what’s next?

You may hear many members of the executive team talking about plan expansion, changes in benefits, new product lines (dual eligibles/Special Needs Plans (SNPs), Annual Election Period (AEP), Open Enrollment Period (OEP), and so much more. But are you wondering how this may affect the Risk Adjustment area and what some of the next key dates are?

New plans or plan expansion can impact your plan risk adjustment. Keep in mind, you had a benchmark set for PY 2019 with your 2017/2018 data, and many of your new members may not have been part of your risk calculation. While the overall approach to risk adjustment is to be a zero-sum game, the reality is, without proper coding, understanding of the health of your members, clean enrollment/eligibility files, and proper claims payment, you may be starting 2019 with more items on your to do list, so keep in mind the following enrollment dates:

  • AEP: October 15 – December 7, 2018
  • The Medicare Advantage Disenrollment Period (MADP) (January 1 – February 14 every year) will be replaced with a different arrangement and will be effective starting in 2019 according to CMS. The MADP lets you drop your Medicare Advantage (MA) plan and return to Original Medicare (Part A and Part B). It also lets you sign up for a standalone Medicare Part D Prescription Drug Plan (PDP).
  • Starting in 2019, a new OEP will occur January 1 – March 31 each year. If you’re enrolled in an MA plan, you’ll have a one-time opportunity to:
    • Switch to a different MA plan
    • Drop your MA plan and return to Original Medicare (Part A and Part B)
    • Sign up for a PDP – if you return to Original Medicare
    • Drop your PDP

Each one of these key dates can impact your risk score with new or reduction in members, change in member mix, as well as an opportunity to review your current policies and procedures to ensure they align with the changes set forth by CMS or your internal Compliance Department.

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