Payers – Marketplace

A Marketplace Portal for Medicare, Medicaid & ACA Risk Adjustment

The Affordable Care Act (ACA) presents expansive opportunities for payers—but also heightened financial risks. With coverage protection for pre-existing conditions, plans that attract a sicker-than-average population face revenue erosion. That’s why a smarter ACA Risk Adjustment strategy, akin to Medicare Advantage programs, is essential.

Why It Matters:

  • ACA’s risk adjustment redistributes as much as 25% of individual health premiums, transferring funds from lower-risk to higher-risk plans. Accurate risk scoring isn’t optional—it’s mission-critical.

How Risk is Measured:

  • ACA issuers must submit member encounter and supplemental chart data in XML format via the HHS EDGE Server. This process is central to establishing eligibility and ensuring accurate risk adjustment transfers. Under-regulated or incomplete submissions risk a default charge, as CMS prohibits plans from benefitting from poor data quality.CMS+1

  • HHS computes plan-level risk scores using its own calibrated HHS-HCC models, which are updated annually with recent EDGE data submissions—most recently using enrollee-level data from 2020–2022 for the 2026 benefit year.CMS+1

Why HDM Makes a Difference:

  • Health Data Max simplifies ACA risk adjustment with secure, validated EDGE submissions and proactive data quality monitoring.

  • We help you meet both quantity and quality thresholds—meeting CMS’s 90%+ enrollment and claims requirements to avoid penalties and ensure inclusion in interim and final transfer reports.CMS+1

  • Our platform enables reconciliation, supplemental diagnoses correction, and deep insight into risk score drivers—helping protect your bottom line.

Bottom Line:
In ACA risk adjustment, the most accurate data wins—and with stakes this high, precision isn’t just smart—it’s essential.