Medicare Advantage Risk Adjustment Recommendations For 2022

 A Risk adjustment Solution estimates healthcare costs that compare a person's health to a number known as a risk score. The "risk" to a health insurance plan covering members with high projected healthcare usage is "adjusted" by covering those with low estimated healthcare costs.

Risk adjustment is a program in which health insurance providers participate and are reimbursed for managing individuals' healthcare requirements depending on their diagnosis.

Since Risk Adjustment programs are devised and maintained by government organizations that exist to serve all entitled members of the general public, a health insurance provider cannot prejudice or cover just the members of a specific demographic with a restricted range of predicted healthcare expenditures. The case mix of both healthy and critical patients and the cost-sharing of spending shared by all members is intended to enable access to quality care regardless of medical condition or history.

Medicare Advantage Plans

Apart from the government's regular Medicare and Medicaid programs, Medicare enrollees have the option of getting services through a variety of private insurance plans. These private insurance alternatives are known as Medicare Advantage (MA) Plans. They are a component of Medicare Part C. MA is a method of obtaining medical services and Medicare coverage.

Recommendation for Medicare Advantage Risk Adjustment in 2022

Considering the critical stay-at-home instructions and regulations throughout 2020, Medicare Advantage providers are now confronted with the issue of insufficient prospects to accumulate encounter data to do comprehensive risk adjustment equations. Concerned about the impact of risk adjustment scores on consumer premiums, benefits packages, and patient out-of-pocket costs, the Alliance of Community Health Plans (ACHP) has requested that CMS amend the MA risk adjustment criteria for the year 2022.

ACHP recommends CMS to permit MA entities to use a 24-month look-back timeframe to enhance 2020 statistics for the assessment of 2021 risk scores. ACHP argues that it allows Medicare Advantage Plans to avoid the detrimental impact of under-risk-adjusting. 

ACHP suggests that CMS create a replicable strategy for 2022 since recent increases in COVID-19 show that the healthcare industry will be under pressure long beyond 2021.

ACHP anticipates that even though COVID-19 vaccination is now available in 2021, there will be a time lag between its supply and the return to regular activities. Considering the fact that vaccine distribution efforts are regulated on a state-by-state basis, it is quite probable that recipients, particularly the most vulnerable, will be unwilling to shift to pre-pandemic standards of care instantly.