As we approach the upcoming Affordable Care Act (ACA) Open Enrollment period starting November 1, it’s crucial for health plans to prepare for what could be another record-setting year. Last year’s open enrollment saw a historic 21.3 million people sign up for ACA Marketplace coverage—marking a 30% increase from the previous year and setting a new record for the fourth consecutive year. With this continued growth, including 5.1 million first-time enrollees, the demand for affordable health insurance shows no signs of slowing down.
This surge presents both opportunities and challenges for health plans. Since ACA plans allow members to enroll without health histories or underwriting, there’s a greater risk of attracting a sicker population, which could impact risk adjustment calculations. Ensuring accurate risk adjustment scores and proper payments becomes critical, especially as enrollment numbers rise.
We’ve outlined three risk adjustment strategies designed to address these challenges and ensure that health plans are prepared for the anticipated influx of members during this year’s enrollment period.
ACA Marketplace plans face higher risk from enrolling members without health histories, potentially impacting risk adjustment scores.
Member Engagement and Health Assessments
Health plans should prioritize engaging new members and encouraging them to schedule annual wellness visits to identify any chronic conditions as early as possible. Telehealth or in-home health assessments can be utilized to provide members with convenient, proactive evaluations. Members can then be referred to primary care providers for management of any conditions requiring further care. Additionally, ACA members who do not seek care will not have HEDIS or quality measures performed that are appropriate based on their demographics, which can negatively impact a plan’s quality ratings. Many of these measures can be addressed in a prospective health assessment with an additional screening.
Strengthen Provider Collaboration
Not all members may present with ACA Risk Adjustment conditions, so each one that is reported is crucial to the health plan’s overall risk score. Since only the primary diagnosis is required for payment, some providers may not report every relevant risk adjustment condition. This means plans must proactively retrieve and review member charts to identify any overlooked conditions. The ACA allows for supplemental diagnosis codes to be collected from medical record reviews and submitted for risk score calculation, which should be an integral part of a health plan’s risk adjustment strategy. The ACA risk adjustment model is concurrent, meaning the risk score is based on the year in which the member is enrolled and receives care under the health plan. Many acute conditions also impact the overall risk adjustment score.
Leverage Analytics
With new members enrolling annually without historical health data, analyzing ACA Risk Adjustment member information can present challenges. Proactive member engagement and regular provider visits can help bridge this information gap. The age range between enrollees may also vary widely, including children and small business employees. While much of this population may be healthy, a lack of routine provider visits can make it difficult to identify underlying conditions until healthcare utilization occurs. The benefits selected may offer some insight into which members may require more healthcare services, but these expectations may not always align with the incoming data. Given that fewer Marketplace members may have risk adjustment conditions, each Hierarchical Condition Category (HCC) captured is valuable and significantly influences risk scores and HHS funds transfers. Therefore, analytics is a critical component of any ACA Risk Adjustment strategy.
Conclusion
As ACA Marketplace enrollment continues to surge, health plans must adapt by prioritizing strategies that ensure accurate ACA Risk Adjustment scores and optimize care for their members. With a focus on member engagement, provider collaboration, and by leveraging advanced analytics, health plans can better manage the challenges of enrolling new, diverse populations and ultimately improve overall outcomes.
Advantmed provides a comprehensive suite of risk adjustment solutions, including advanced analytics, medical record retrieval, risk adjustment coding, quality abstraction, and in-home and virtual health assessments. Our health assessments extend care beyond traditional clinical settings, capturing critical health information that might otherwise be missed—ensuring health plans have the complete information needed to optimize their risk adjustment scores.
For more information on Advantmed’s risk adjustment solutions, click here.