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Patient Protection and Affordable Care Act (PPACA) › Risk Adjustment Formula

The Patient Protection and Affordable Care Act (PPAC), also known as Obamacare, is a United States federal statute passed in March of 2010. The Act creates a nationwide insurance system and provides federal... more +
The Patient Protection and Affordable Care Act (PPAC), also known as Obamacare, is a United States federal statute passed in March of 2010. The Act creates a nationwide insurance system and provides federal subsidies to reduce the number of uninsured citizens. less -
Blank Rome LLP

Another Defunct Small Health Insurer Fails in Challenge to ACA Risk Adjustment Rules

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The Fifth Circuit Court of Appeals recently rejected a slew of claims by Vista Health Plan, Inc. (“Vista”) seeking to invalidate the 2017 and 2018 regulations governing the risk adjustment program that applies to individual...more

Sheppard Mullin Richter & Hampton LLP

Fifth Circuit Upholds ACA Risk Adjustment Program

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Various smaller health insurance issuers have challenged the risk-adjustment program under the Patient Protection and Affordable Care Act (ACA), alleging, among other things, that its underlying methodology favors larger...more

Sheppard Mullin Richter & Hampton LLP

Biden Administration Finalizes Lower Out-of-Pocket Costs for Exchange Plans, Targets Health Equity and Access

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The Biden Administration used the annual rulemaking that governs health plans sold on the Affordable Care Act’s exchanges to lower health care costs for consumers and improve access to health care. Part 2 of the Notice of...more

Manatt, Phelps & Phillips, LLP

[Webinar] COVID-19: The Road Ahead for Commercial Health Insurance - April 23rd, 2:00 pm - 3:00 pm ET

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Examine the Evolving Challenges That Lie Ahead for Healthcare Stakeholders and State Regulators—and What You Can Do Now to Prepare and Protect Your Organization—at a New Manatt Webinar. Effective health insurance...more

King & Spalding

Tenth Circuit Upholds HHS Risk Adjustment Methodology

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On December 31, 2019, a 3-0 panel of the United States Court of Appeals for the Tenth Circuit upheld the methodology adopted by HHS to administer the risk adjustment program under the Affordable Care Act (ACA). See New Mexico...more

Mintz - Health Care Viewpoints

Did the Tenth Circuit Just Put the Final Nail in the Coffin for Challenges to the Use of “Statewide Average Premium” in Risk...

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On December 31, 2019, the Tenth Circuit Court of Appeals upheld the Department of Health & Human Services’ Affordable Care Act (ACA) risk adjustment methodology in New Mexico Health Connections v. HHS, No. 18-2186 (10th Cir....more

Carlton Fields

Court of Federal Claims Finds HHS Offset Invalid Under Colorado’s Insurance Liquidating Priority Scheme

Carlton Fields on

The U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (HHS) operates the reinsurance and risk-adjustments program for Colorado, including the application of the “netting rule” — a method...more

Mintz - Health Care Viewpoints

New Mexico Court Affirms Ruling in ACA Risk Corridor Case

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On October 19, 2018, a New Mexico district judge rejected a request from HHS to reconsider a February decision that had briefly led to the suspension of the ACA’s risk adjustment program. In February, District Judge James...more

Mintz - Health Care Viewpoints

Court Rules that Federal Government Must Make Cost Sharing Reduction Payments to Insurers

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ACA plans scored a major victory last week when a federal court held that health plans participating on the ACA exchanges are entitled to unpaid cost sharing reduction (CSR) payments from the federal government. The case –...more

Farrell Fritz, P.C.

State Reallocation of FRAP Funds Not Barred By the ACA

Farrell Fritz, P.C. on

As the battle over the future of the Affordable Care Act (the “ACA”) continues, New York State scored a big victory earlier this month with the federal court decision of UnitedHealthcare of New York, Inc., et al. v. Vullo....more

Mintz - Health Care Viewpoints

CMS, In a Reversal, Announces Plans to Continue Funding Risk Adjustment Payments

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On Wednesday, August 8, CMS filed a proposed rule clearing the way for the federal government to continue making payments under the ACA’s risk adjustment program for the benefit year 2018. The 2018 proposed rule is...more

Sheppard Mullin Richter & Hampton LLP

No Longer in Suspense: CMS Issues Final Rule Announcing that Risk Adjustment Program Transfers for 2017 will be Distributed in...

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The Final Rule. In a Final Rule posted by CMS last Tuesday, July 24, 2018, CMS announced that $10.4 billion in “risk adjustment transfers” (“Risk Transfers”) for benefit year 2017 (as calculated pursuant to the Affordable...more

Baker Donelson

CMS Reinstates ACA Risk Adjustment Payments

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On Tuesday, July 24, the Centers for Medicare and Medicaid Services (CMS) issued a final rule intended to clarify the program methodology and reinstate payments under the Affordable Care Act's (ACA) permanent risk adjustment...more

King & Spalding

Insurers Not Entitled to Full ACA Risk Corridors Payments Says the United States Court of Appeals for the Federal Circuit

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Resolving a split in the lower courts, the Federal Circuit issued two decisions on June 14, 2018, wherein the Court held that health insurers Moda Health Plan Inc. (Moda Health) and Land of Lincoln Mutual Health (Land of...more

Manatt, Phelps & Phillips, LLP

Manatt on Health Reform: Weekly Highlights - August 2016 #5

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A federal report finds that Marketplace premiums are lower in expansion states; Massachusetts and Pennsylvania launch prescription drug monitoring systems; and Kentucky submits a slightly modified Medicaid expansion waiver to...more

Manatt, Phelps & Phillips, LLP

Manatt on Health Reform: Weekly Highlights - August 2016 #3

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CMS’s risk adjustment program data signals an improving risk pool while the agency announces plans to modify the program; California enrolls 134,000 undocumented immigrant children into Medicaid; and Oregon approves increases...more

Manatt, Phelps & Phillips, LLP

Manatt on Health Reform: Weekly Highlights - August 2016 #2

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CMS targets Medicaid managed care pass-through payments; California proposes “California Qualified Health Plans” for the undocumented; and a new study finds out-of-pocket costs were reduced by nearly a third for Medicaid...more

Sheppard Mullin Richter & Hampton LLP

Maryland Co-Op Claims Risk Adjustment Formula Discriminates Against Smaller Insurers

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Maryland’s Evergreen Health Cooperative has filed for an injunction against the federal government to halt payment by the Consumer Operated and Oriented Plan (co-op) of the $22 million it owes to CareFirst BlueCross...more

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