Principle 5— Issuers should not be penalized for a provider prescribing additional NDCs or coding additional medical conditions (monotonicity).
Principle 6— Should be able to map a drug or service to the primary ACF.
Principle 7— Should not include ACFs that are particularly subject to prescribing variation or inappropriate prescribing.
Hepatitis C Drugs Adjustment
The market pricing adjustments related to Hepatitis C drugs in the HHS risk adjustment models are proposed to begin phasing out.[5] Specifically, market specific pricing adjustments were developed and applied to EDGE experience to reflect unique pricing changes that resulted from new and generic Hepatitis C, which did not align with other specialty drug categories. Recently, HHS indicated Hepatitis C drug prices are increasing similar to other specialty drug categories. The proposal will use unique market pricing adjustments for these drugs to the 2025 benefit year as with prior years, but to trend for the 2026 benefit year, they will use the specialty drug trend factor.
Risk Adjustment Data Validation (RADV)
Risk adjustment data validation is the process by which HHS verifies the quality and accuracy of the data used in the risk adjustment calculation.
HHS proposed revisions to their sampling procedure. Several proposals were included, which are quite detailed and technical, so we have not summarized.[6]
HHS also proposed to set a minimum materiality threshold for rerunning RADV results in the case of an appeal, which is resource and time intensive, to $10,000.[7] Currently, there is no specific rule as to when HHS would be required to rerun HHS-RADV in response to an appeal, although issuers may dispute if the amount exceeds 1% of the applicable payment or charge from the issuer for the benefit year OR $10,000, whichever is less.
[5] B. 45 CFR Part 153—Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment – 2. HHS Risk Adjustment (§153.320) – b. Pricing Adjustment for the Hepatitis C Drugs
[6] 6. Risk Adjustment Data Validation Requirements When HHS Operates Risk Adjustment (HHS–RADV) (§§153.350 and 153.630) 6. Risk Adjustment Data Validation Requirements When HHS Operates Risk Adjustment (HHS–RADV) (§§153.350 and 153.630)
[7] 6. Risk Adjustment Data Validation Requirements When HHS Operates Risk Adjustment (HHS–RADV) (§§153.350 and 153.630) 6. Risk Adjustment Data Validation Requirements When HHS Operates Risk Adjustment (HHS–RADV) (§§153.350 and 153.630) b. c. HHS–RADV Materiality Threshold for Rerunning HHS–RADV Results (§156.1220(a)(2)) and C. Part 155—Exchange Establishment Standards and Other Related Standards – 10. HHS–RADV Materiality Threshold for Rerunning HHS–RADV Results (§156.1220(a)(2))