Code of Massachusetts Regulations
956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY
Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market
Section 13.05 - Transfer Calculation and Payment

Universal Citation: 956 MA Code of Regs 956.13

Current through Register 1531, September 27, 2024

(1) The Connector will annually complete fund transfer calculations according to the Risk Adjustment Methodology established by the Connector for the applicable Benefit Year. The calculations will be based on the data that has been reported to CHIA as of April 30th of the year following the applicable Benefit Year.

(2) If a Carrier fails to submit data or submits inaccurate or incomplete data to the MA APCD within the timeframe required, such that the Connector cannot apply the applicable Risk Adjustment Methodology to calculate the risk adjustment payment transfer amount in a timely fashion, the Connector may assess a default risk adjustment charge, calculated according to the methodology established by the Connector for the applicable Benefit Year.

(3) The Connector will issue a Final Risk Adjustment Payments and Charges Report to each Carrier by July 1st of the year following the applicable Benefit Year, reporting on the calculation of risk scores and transfer payments. The report will state the amounts of the risk adjustment charges that must be paid or transfer payments that will be received by the Carrier.

(4) Carriers that are assessed risk adjustment charges must pay the amount specified in the Final Risk Adjustment Payments and Charges Report provided by the Connector within 30 calendar days after issuance of the Final Risk Adjustment Payments and Charges Report, in accordance with instructions provided by the Connector.

(5) Risk adjustment charges shall be subject to an interest rate of twelve per cent per annum that will begin to accrue 40 calendar days after issuance of the Final Risk Adjustment Payments and Charges Report stating those charges.

(6) Following receipt of charges from Carriers that are assessed charges, the Connector will, from the charges received, make payments to Carriers that are owed risk adjustment payments. Transfer payments will be made after and only to the extent of receipt of risk adjustment charges. To the extent that the Connector has not received full payment of all risk adjustment charges by the due date, the Connector will distribute payments to recipient Carriers on a pro-rated basis, proportional to the total risk adjustment payments due to each Carrier. If, after making the initial payments, the Connector receives additional risk adjustment charges from Carriers making late payments, additional payments will be made to recipient Carriers on a pro-rated basis, proportional to the total risk adjustment payments due to each Carrier.

(7) If a Carrier that is owed a risk adjustment transfer payment for a particular calendar year has at that time an unpaid risk adjustment charge from a prior year, the amount of the transfer payment will be reduced by the amount of the unpaid charge.

(8) A Carrier's compliance with the requirements of the Risk Adjustment Program, including submitting accurate and timely data and making required risk adjustment transfer payments in a timely manner, shall be considered a condition of participation as a qualified health plan offered through the Connector, and a Carrier's failure to comply with these requirements constitutes grounds for the Connector to de-certify that Carrier as a qualified health plan.

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