course material

1. Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid ServicesCriticism of the Decision by the Centers for
Medicare and Medicaid Services (CMS) to Suspend Risk-Adjustment PaymentThe risk-
adjustment policy was enacted under the Patient Protection and Affordable Care Act 2010
or “Obamacare”. It is designed to offset the extra costs incurred by insurers who provide
coverage to a comparatively larger population of individuals with a higher risk of disease
burden. Usually, these are individuals who have pre-existing medical conditions such as
diabetes, hypertension, and heart conditions. The model centers around giving risk scores
to the people who have been covered. The model does not however work by making the
insured pay higher premiums. Rather, it obligates those insurers who cover higher numbers
of healthier individuals to contribute to a risk-adjustment pool from where extra money can
be drawn to compensate those insurers with higher numbers of sicker individuals. It
therefore provides an incentive for payers to continue covering citizens who are older and
with pre-existing conditions. This paper summarizes an article in the Mental Health Weekly
about this subject and poses two questions at the end to be answered.Centers for Medicare
and Medicaid ServicesORDER A PLAGIARISM-FREE PAPER HEREThe Article by Canady
(2018)Canady (2018) writes that several medical groups went up in arms about a decision
by the Centers for Medicare and Medicaid Services to withhold billions of dollars that were
supposed to be paid to insurers. This is incentive money that is supposed to be paid to those
insurers that provide cover to older and sicker individuals, usually with pre-existing
conditions. The decision was announced by the CMS on July 7. Some of the bodies that sent
protest letters to the CMS concerning this action were the National Patient Advocate
Foundation, the American Medical Association, and the National Alliance on Mental Illness
(NAMI). They argued that the action by the CMS jeopardised the prospects of vulnerable
citizens accessing affordable medical care. They also posited that it also risked exposing
vulnerable populations to higher premiums charged by the insurers who will be lacking an
incentive to continue covering individuals who are sickly and suffering from pre-existing
conditions (Canady, 2018).Centers for Medicare and Medicaid ServicesThe protesters noted
that the trigger for this action by the CMS was the presence of litigation in the justice system
concerning the matter of the risk-adjustment policy. This was the case of New Mexico
Health Connections v. HHS. The concern of these protesting organizations and bodies was
that the payment of these risk-adjustment moneys amounting to about USD 10.4 billion
would not be made until the above case was heard and concluded. During this hiatus,
therefore, the insurers that provide coverage to individuals with chronic conditions may

2. decide to raise their premiums for the following year. This would put many of the
beneficiaries of the Affordable Care Act 2010 out of healthcare insurance coverage by the
simple fact that they would not afford the new premiums. This would definitely negate the
very objective why the Patient Protection and Affordable Care Act 2010 was enacted in the
first place (Canady, 2018). The millions of new citizen members that came within the
bracket of healthcare coverage as a result of ACA 2010 would definitely be rendered
without cover due to expensive premiums.Questions to be Answered by PeersIn your
opinion, do you think that the risk-adjustment model enshrined in the ACA 2010 was meant
to be sustainable?Do you think repealing and replacing the risk-adjustment provision in the
ACA is a solution to increasing healthcare coverage for citizens?ReferencesCanady, V.A.
(2018). CMS urged to reconsider risk-adjustment payment decision. Mental Health Weekly,
28(28), 7-8. Doi: 10.1002/mhw.31528 Centers for Medicare and Medicaid Services