HHS-RADV Webinar Series: 2019 Benefit Year Updates
Join the HHS-RADV webinar series for updates on protocols and guidelines for the 2019 benefit year. Learn about session agenda, stakeholder guidelines, Q&A submissions, and technical tips for optimal webinar experience.
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This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regulations that it is based on. We encourage audience members to refer to the applicable regulations for complete and current information about the requirements that apply to them.
HHS Risk Adjustment Data Validation (HHS-RADV) Webinar Series V 2019 Benefit Year HHS-RADV Protocol Updates from Stand Alone Rule, Error Estimation April 7, 2021 This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regulations that it is based on. We encourage audience members to refer to the applicable regulations for complete and current information about the requirements that apply to them.
Session Agenda Session Guidelines Intended Audience and Session Purpose HHS-RADV Timeline and Announcement 2019 Benefit Year HHS-RADV Protocols Updates Question & Answer (Q&A) Next Steps & Resources 3
Session Guidelines This is a 60-minute webinar session Stakeholders may listen to today s event via their computer speakers or telephone To listen through your computer speakers, please ensure your computer volume is not muted To listen through your telephone, dial 1-866-442-5690 and enter your unique six-digit Personal Identification Number (PIN) If you cannot hear today s audio or are having other technical issues, please contact the Registrar at registrar@regtap.info or (800) 257-9520 4
Session Guidelines (continued) To submit a question during today s webinar Type into the Q&A panel on the lower, right-hand side of your screen Hit the Send button to submit your question to CMS Please email additional content questions to CCIIOACARADataValidation@cms.hhs.gov For questions regarding logistics and registration, please contact the Registrar at registrar@regtap.info or (800) 257-9520 5
Webinar and Audio Access Tips Hardwire your computer as opposed to using Wi-Fi Close unnecessary applications and browser sessions on your device for better connectivity Reduce simultaneous streaming activities by others in your current workplace/home to increase your bandwidth Disconnect from any Virtual Private Network (VPN) if able and applicable for the best experience Switch to phone if you lose web connectivity or sound when listening through your computer The telephone number is 866-442-5690 and your individual PIN is included in your meeting reminder email 6
Intended Audience Issuers subject to the HHS-RADV Audit requirements under 45 CFR 153.630 State Regulators/State Agencies Initial Validation Audit (IVA) Entities Third Party Administrators (TPAs), Pharmacy Benefit Managers (PBMs), and Support Vendors 7
Session Purpose For the Centers for Medicare & Medicaid Services (CMS) to provide an overview of all updates made to the 2019 Benefit Year HHS-RADV Protocols including updates to the error estimation procedures based on the HHS-RADV Amendments Final Rule, published on December 1, 2020 (85 FR 76979) 8
HHS-RADV Timeline 9
2019 Benefit Year Date January 19 September 1, 2021 July 1, 2021 September 1, 2021 Activities and Descriptions Issuers IVA Entities conduct the IVA Audit Tool opens for IVA testing and submissions Deadline for IVA Entities submission of Package 1 audit findings and issuer signoff CMS closes Package 1 submission window at 8:00 p.m. ET Deadline for IVA Entities submission of sampled enrollees medical records (Package 2) to CMS for the SVA subsample and issuer signoff CMS closes the Package 2 submission window at 8:00 p.m. ET Deadline for IVA Entity Inter-rater Reliability (IRR) submission CMS SVA Entity conducts the SVA 2019 Benefit Year HHS-RADV Summary of Final Pairwise Results Summary of Final Pairwise Results released to all issuers SVA Findings Report released only to HIOS ID(s) with Insufficient Agreement 2019 Benefit Year SVA Findings Report Attestation and Discrepancy Reporting for HIOS ID(s) with Insufficient Agreement (30-day discrepancy window) occurs (exact date forthcoming) September 9, 2021 September 9, 2021 September 9 December 2021 December 2021 30-calendar day window after release of Final Pairwise Results (December 2021 January 2022) 10
2019 Benefit Year (continued) Date Activities and Descriptions February 2022 30-calendar day window after release of HHS-RADV Final Results Memo and issuer/enrollee-level results (February 2022 March 2022) May 2022 2019 Benefit Year Results Report Suite is released (exact date forthcoming) 2019 Benefit Year HHS-RADV Error Rate Calculation Discrepancy period (30-day discrepancy window) occurs (exact date forthcoming) CMS releases the 2019 and 2020 Benefit Year HHS-RADV Results Memo and issuer/enrollee-level results to issuers (Exact date to be determined) CMS releases the Summary Report of 2019 and 2020 Benefit Years HHS-RADV Adjustments to Risk Adjustment Transfers 2019 Benefit Year SVA Findings Report Reconsiderations and Error Rate Methodology Reconsiderations period (30-day reconsideration window) occurs Summer 2022 30-calendar day window after release of Summary Report of 2019 Benefit Year Risk Adjustment Data Validation Adjustments to 2020 Benefit Year Risk Adjustment Transfers 11
2020 Benefit Year Date March 2021 March 17 April 30, 2021 April 12, 2021 April 30, 2021 Activities and Descriptions Issuers contractually select IVA Entities for 2020 benefit year HHS-RADV IVA Entities start to elect to participate for 2020 benefit year HHS-RADV Issuers start to designate IVA Entities within the HHS-RADV Audit Tool 2020 benefit year Risk Adjustment (RA) External Data Gathering Environment (EDGE) server data submission deadline May 2021 Release 2020 Benefit Year HHS-RADV Protocols HHS-RADV samples are generated 1. CMS deploys preliminary HHS-RADV sampling command to EDGE servers. Issuers should execute the command by the designated date 2. CMS validates reports. Reports are NOT available to issuers 3. CMS deploys final HHS-RADV command to EDGE servers to release sampling reports to issuers 4. The 15-calendar day HHS-RADV sample discrepancy window opens after the final HHS- RADV command is deployed by CMS (Exact dates will be determined) May 2021 12
2020 Benefit Year (continued) Date Activities and Descriptions CMS identifies and notifies eligible issuers of exemptions: CMS notifies eligible issuers identified as having $15 million or less in total premiums statewide who are exempt from the 2020 benefit year HHS-RADV IVA and Second Validation Audit (SVA) Requirements under 45 CFR 153.630(g)(2) and have not been selected for random or targeted sampling for 2020 benefit year HHS-RADV CMS notifies issuers identified as having 500 or fewer billable member months statewide who are exempt from 2020 benefit year HHS-RADV IVA and SVA requirements under 45 CFR 153.630(g)(1) CMS notifies issuers identified as only issuer in a state risk pool market (sole market risk pool issuers) and issuers offering only small group carry over coverage for the applicable benefit year who are exempt from 2020 benefit year HHS-RADV CMS will instruct eligible exempt issuers how to complete the 2020 Benefit Year HHS-RADV Issuer Exemption and DDVC Web Form May 2021 June 2021 January 2022 November 2021 Issuers and IVA Entities conduct the 2020 benefit year IVA Audit Tool opens for IVA Testing and Submission (Exact date to be determined) 13
2020 Benefit Year (continued) Date January 13, 2022 Activities and Descriptions Deadline for IVA Entities submission of Package 1audit findings and issuer signoff CMS closes the Package 1 submission window at 8:00 p.m. ET Deadline for IVA Entities submission of sampled enrollees medical records (Package 2) to CMS for the SVA subsample and issuer signoff CMS closes the Package 2 submission window at 8:00 p.m. ET January 20, 2022 January 20, 2022 January 2022 April 2022 IVA Entity Inter-rater Reliability (IRR) submission is due CMS SVA Entity conducts the SVA 2020 Benefit Year Summary of Final Pairwise Results HIOS ID(s) with Sufficient and Insufficient Agreement are released to issuers (Exact date to be determined) March 2022 30 calendar day window after release of Final Pairwise Results 2020 Benefit Year HHS-RADV SVA Findings Report Attestation and Discrepancy Reporting period for issuers with insufficient agreement of final pairwise results (Exact date to be determined) 14
2020 Benefit Year (continued) Date Activities and Descriptions CMS releases the 2019 and 2020 Benefit Year HHS-RADV Results Memo and issuer/enrollee-level results to issuers (Exact date to be determined) May 2022 30 calendar day window after release of HHS-RADV Error Rates Final Results Memo and issuer/enrollee-level results 2020 Benefit Year Error Rate Calculation Attestation and Discrepancy Reporting period (Exact date to be determined) CMS releases the Summary Report of 2019 and 2020 Benefit Years HHS-RADV Adjustments to Risk Adjustment Transfers Summer 2022 30 calendar day window after release of report setting forth 2020 HHS- RADV adjustments reflected in 2020 benefit RA transfers 2020 Benefit Year Request for Reconsideration period (Exact date to be determined) 15
HHS-RADV Announcement 16
HHS-RADV Announcement The 2019 Benefit Year HHS-RADV Protocols (add link here) were published to the Registration for Technical Assistance Portal (REGTAP) on {March XX, 2021} 17
2019 Benefit Year HHS-RADV Protocols Updates 18
2019 Benefit Year HHS-RADV Protocols Updates Section Update General Rreorganization of Protocols All Sections Simplified the overall language and reorganized the sections to improve clarity of the HHS-RADV audit guidance Each section includes a short overview of the section content and includes, where applicable, a list of 2019 benefit year specific changes or updates Included policy guidance related to the applicable proposals finalized in the 2021 Payment Notice that is are effective for the 2019 benefit year HHS-RADV audit Provided clarity Clarified for the audit process operational guidelines guidance based on IVA Entity and Issuer Lessons Learned, as well as stakeholder questions captured from the 2018 benefit year HHS-RADV audit 19
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 1.2.2 HHS- RADV Program Clarified guidance stating that issuers should review their HHS-RADV Sampling Reports to ensure they are representative of the issuer s population in the risk pool markets Clarified guidance stating that upon issuers review of HHS-RADV Sampling Reports, the issuer must complete the HHS-RADV Attestation and Discrepancy reporting process 20
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 1.2.6.1 Exemption from HHS-RADV Clarified that exemptions are determined at the Health Insurance Oversight System (HIOS) ID level, not the issuer company level Issuers with multiple HIOS IDs may have some HIOS IDs exempt and some required to participate in HHS-RADV for a given benefit year 21
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 3.2.2 HHS- RADV Process Timeline Delayed start to timeline and shifted deadlines for the 2019 benefit year HHS-RADV due to the Coronavirus 2019 (COVID-19) public health emergency Clarified that upon issuer sign-off of Package 1, the issuer is acknowledging agreement with IVA findings and understands that there is no right to file a discrepancy or appeal the IVA findings to CMS 22
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 7.2.2.1.1 Neyman Allocation Update Included policy guidance (where applicable) related to Updated to reflect the proposal finalized in the final 2020 Payment Notice to apply the Neyman optimal sample allocation method to all strata [Strata 1-10] beginning with 2019 benefit year HHS-RADV More specifically, the changes reflect that the Neyman optimal sample allocation method is applied to all strata [Strata 1-10] Prior to 2019 benefit year HHS-RADV, Stratum 10 (enrollees without HCCs) did not have the Neyman optimal sample allocation method applied This optimizes issuers IVA samples with the goal of improving precision results when compared to the one-third/two-thirds approach used in prior benefit years Prior to the 2019 benefit year HHS-RADV, two-thirds of the total sample size was allocated to the Hierarchical Condition Category (HCC) strata [Strata 1- 9] with the remaining one-third assigned to the No HCCs and No RXCs Stratum 10 23
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 8.3.3.2 Verify Representativeness of IVA Sample Added procedural steps to help allow issuers to check whether the IVA sample appears representative of the total issuer HHS-RADV population risk 24
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Section 9 Audit Execution Update Updated title to Section 9 Audit Execution from the previous 2018 benefit year title Audit Procedures and Reporting Requirements Updated procedural sub-steps to clarify and consolidate audit requirements, and to enhance enhanced ordering, including consolidation of mapping documentation requirements Renamed Phase 1 from Creating D&E Mapping Documentation (Issuer) to Create Supporting Documents Section 9.2.12 Moved all information guidance from Appendix B D&E Subsample Data Elements (of the 2018 benefit year version) into Section 9.2.4.2.1 Validation of D&E Data Elements and removed D&E guidance from the Appendices 25
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 9.2.2.1.3.3 Mapping Claim Processed Data and Time Updated and clarified how to use requirements for RXC validation in mapping documentation and workpapers for specific to systemic issues identified in within issuers External Data Gathering Environment (EDGE) data submissions during RXC validation of the related to prescription drug claim data element Claim Processed Date Time Clarified language to indicate that Claim Processed Date Time values do not need to be within the benefit year being audited but must confirm the claim is in a paid/positively adjudicated status. 26
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 9.2.2.2 Source System Documentation (Screenshots) Clarified that issuers may grant IVA Entities access to their source system(s) to obtain screenshots required for audit purposes 27
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 9.2.2.4.1 Medical Record Submission Guidance Update Updated Medical Record Submission Guidance to clarify that an IVA Entity may, after consulting with the issuer, identify any medical records reviewed by the IVA Entity in the IVA Entity Audit Results Submission XML regardless of whether or not the medical records were valid or a diagnosis was abstracted In cases of disagreement on validity of a medical record or diagnosis coding between the issuer and the IVA Entity, IVA Entities should follow issuer guidance on which medical records the IVA Entity should submit to the Audit Tool The RADV IVA Submission XML ICD and XML Data Elements Job Aid located in the Audit Tool library provides further technical requirements details 28
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 9.2.4 Phase 3 D&E Data Validation Update Clarified that four (4) or more errors present for a single data element in a HIOS ID constitutes a failed Demographic and Enrollment (D&E) status and requires additional outreach to issuers to determine if further actions are required 29
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 9.2.5 Phase 4 RXC Validation Update Updated to reflect that the operation of the 2019 benefit year HHS-RADV RXC validation will be a second pilot year, as finalized in the 2021 Payment Notice 30
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 9.2.5.2 Identifying RXC Source Update Provided additional details specifying how National Drug Codes (NDCs) in Do-it-Yourself (DIY) Table 10a are provided in the HIPAA NDC 11 format, and clarified that issuers and IVA Entities must coordinate to identify the appropriate HIPAA NDC 11 codes for medications, which crosswalk to RXCs in the RA model and referenced in DIY Table 10a 31
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 9.2.6.5.1 Cross Year Claims Update Clarified that dates of service or claim dates for future dates beyond the applicable benefit year are not allowed for HHS-RADV, including dates of service associated with Lifelong Permanent Conditions Clarified that diagnoses made prior to the applicable benefit year that are associated with Lifelong Permanent Conditions may be abstracted from medical records and claims with acceptable dates of service as long as the requirements in Section 9.2.6.6 Acceptable Date of Medical Record or Claim are met 32
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 9.2.6.10.1 Medical Record Attestations Update Updated provider attestation guidance to specify that an issuer should submit workpaper documentation if a provider attestation cannot be obtained for any reason (e.g., physician death, left the practice, or no longer practicing) and the issuer elects to submit an unauthenticated and invalid medical record Please Note: Absence of a signature or attestation will render the medical record invalid for diagnosis abstraction for HHS-RADV, including but not limited to if reviewed by the SVA in the selected sample 33
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 11.3.3 Error Estimation Analysis Processes Updated to reflect applicable policies finalized in the 2020 HHS-RADV Amendment Rule, to state note that for 2019 benefit year non-exiting issuers, benefit year 2019 and 2020 HHS-RADV error rates will be averaged and applied to 2020 plan liability risk scores to adjust transfers From 2021 benefit year HHS-RADV onwards, plan liability risk scores and transfers will only be adjusted based on the same benefit year s HHS- RADV results 34
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 11.3.3.1 Categorize All Super HCCs into Three (3) Groups Updated the hierarchical condition categories (HCC) grouping process to reflect with the revised methodology finalized in the 2020 HHS-RADV Amendments Rule, which aggregates HCCs that are in the same HCC coefficient estimation groups in the adult risk adjustment models into a composite HCC called a Super HCC prior to sorting them into Low, Medium, and High Failure Rate Groups (85 FR 76979) 35
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 11.3.3.2.2 Identify Issuer Outliers Added a minimum HCC frequency threshold required for an issuer to be identified considered as an outlier. to reflect the policy As finalized in the 2021 Payment Notice, whereby issuers are not considered an outlier for an HCC failure rate group in which the issuer has fewer than 30 EDGE HCCs (85 FR 29164) 36
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 11.3.3.2.3 Calculate the GAF for Outlier Issuers Updated the method for outlier detection and calculation of the Group Adjustment Factor (GAF). to reflect the revised methodology As finalized in the 2020 HHS-RADV Amendments Rule Beginning with the 2019 benefit year HHS-RADV, CMS will identify outliers and apply a sliding scale adjustment on outlier issuers with group failure rates (GFRs) between the 90 and 99.7 percent confidence intervals, and adjust issuers to the mean if their GFR falls outside of the 99.7 percent confidence interval thereby mitigating the payment cliff effect experienced between issuers inside and outside the confidence intervals in prior years, where CMS applied a 95 percent confidence interval and adjusted to the mean for all outlier issuers (85 FR 76979) 37
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update 11.3.3.2.3 Calculate the GAF for Outlier Issuers (continued) Incorporated a constraint to be applied to the GAF calculation for negative error rate outliers with negative failure rates Aas finalized in the 2020 HHS-RADV Amendments Rule, Tthe GAFs for negative error rate outlier issuers with negative failure rates will would be calculated as the difference between zero (0) and the weighted mean failure rate for the HCC grouping (85 FR 76979) 38
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section 11.3.4 Illustration of the Pairwise and Error Estimation Processes adjustment factors, and national failure rate groups Update Illustrated example of the pairwise and error estimation processes was updated based on the procedural changes noted above and on the previous slides Updated text to clarify the impact of newly identified HCCs in the calculation of adjusted enrollee risk scores, issuer Integrated Error Estimation calculation details previously located in Appendix H - Error Estimation Example (of the 2018 benefit year HHS-RADV Protocols). Specifically, guidance associated with establishing final enrollee results and determining HCC failure rate groups, calculating issuer GFRs and GAFs, and determining final issuer error rates Removed stand-alone Error Estimation Example from Appendix as a result of the update detailed above 39
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update Appendix A: 2019 Benefit Year Documentation Examples Updated title of Appendix A 2019 Benefit Year Documentation Examples to reflect that the guidance and examples provided are applicable to all workpaper documents developed for HHS-RADV 40
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Appendix B: Prescription Drug Categories (RXCs) for the 2019 Benefit Year Risk Adjustment Adult Models Update Updated the title to Appendix B Prescription Drug Categories (RXCs) for 2019 Benefit Year Risk Adjustment Adult Models . Formerly, Appendix C was titled Final Diagnosis (RXC-HCC) Pairs for the 2018 Adult Model The following updates were made to Table 42: In alignment with the 2019 Benefit Year HHS-Developed RA Model Algorithm DIY Software Table uUpdates: RXC 6a becomes RXC 6 (Anti-Diabetic agents except Insulin & Metformin); RXC 6b becomes RXC 7 (Insulin); RXC 7 becomes RXC 8 (Multiple Sclerosis Agents); RXC 8 become RXC 9 (Immune Suppressants and Immunomodulators); RXC 9 becomes RXC 10 (Cystic Fibrosis Agents) Removed RXC 11 and RXC 12 . RXC 11 and RXC 12, the two (2) severity- only RXCs, were removed beginning with the 2019 benefit year adult RA models per the 2019 Payment Notice 41
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Appendix C: Lifelong Permanent Conditions Update Streamlined verbiage contained in and updated the format of Figure N: Abstraction of Lifelong Permanent Conditions decision tree Updated Table 43 to include a new condition: HCC 113 (Cerebral Palsy, Except Quadriplegic) Updated examples to reflect current, Lifelong Permanent Conditions list Moved link and content from former Appendix D ICD-10-CM Official Guidelines for Coding and Reporting to Appendix C 42
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Appendix D: Additional Considerations for Coders Update Updated the title and converted the former Appendix F Guidance to Coders into Appendix D Additional Considerations for Coders Added D1 list of Medical Record Requirements Added under Acceptable Provider Credentials Signed By as an example of an acceptable electronic signature Clarified that CMS accepts electronic point of service medical records without an electronically signed by date as an acceptable format for provider signature Clarified that Non-EDGE Claims (NECs) may not be used to validate cross-year claims 43
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update Appendix E: Examples of Applying HHS- HCC Hierarchies Added example describing the revised HCC grouping methodology where a different HCC is discovered, but because they are in the same HCC group, the newly discovered HCC does not impact the failure rate 44
2019 Benefit Year HHS-RADV Protocols Updates (continued) Section Update Appendix F: HHS- RADV Super HCCs and Corresponding Single HCCs for 2019 Benefit Year HHS-RADV (All HCCs) Revised Appendix F to outline a list of all 2019 HHS-RADV Super HCCs, including single HCCs that do not share a coefficient estimation group Removed Error Estimation calculation details previously in Appendix F and integrated into Section 11.3.4 Illustration of the Pairwise and Error Estimation Processes 45
Q&A 46
Questions To ask a question Type into the Q&A panel on the lower, right-hand side of your screen Hit the Send button to submit your question to CMS Please email additional questions to the CMS RADV team at CCIIOACARADataValidation@cms.hhs.gov 47
Resources 48
Locating HHS-RADV Documents in REGTAP Stakeholders can access additional documents in the REGTAP library at https://www.REGTAP.info Under Program Area, select HHS Risk Adjustment Data Validation (HHS- RADV) 49
Upcoming Webinar Topic 2019 Benefit Year HHS-RADV Required Medical and Prescription Drug Category (RXC) XML Data Elements & Interface Control Document (ICD) Date April 14, 2021 50
