The Accountable Care Act (ACA) has created opportunities as well as some challenges for payers. Because Payers cannot deny coverage to individuals due to pre-existing conditions, they are at risk of losses if high proportion of sicker population gets enrolled in the plan. 

It's more imperative than ever to have a smarter Risk Adjustment Program in ACA, similar to how Payers work in Medicare Advantage. However, the key difference between ACA Risk Adjustment Program vs Medicare Advantage Risk Adjustment, is that ACA program redistributes portion of (sometimes as high as 25%) individual health premiums from low-risk to high-risk plans.

In order to quantify the risk of their population, ACA plans need to submit their member encounter data, and supplemental chart review data in the form of XML (Xtensible Markup Language) files to Health and Human Services (HHS Portal). Commonly known as EDGE server submission, this process ensures accurate submission and receipt of risk adjustment data. Contact Us today for your ACA EDGE submissions. But it's more than that.

Similar to Medicare Advantage CMS-HCC driven risk models, HHS also uses it's calibrated HCC models to calculate the risk of each plan as a whole (different from MA where risk score is calculated at member level) and distributes premiums between plans accordingly. 

In other words, whichever ACA plan is savvy enough to submit accurate data wins!