Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: September 28, 2018

Program Area: Risk Adjustment (RA)

Question: What is the holdback percentage for the 2017 Benefit Year (BY) Risk Adjustment (RA) program?

Answer: For the 2017 BY, RA payments made from Fiscal Year (FY) 2018 resources (October 1, 2017 through September 30, 2018) will be held back at a rate of 6.6%. See the HHS Notice of Benefit and Payment Parameters for 2019 Final Rule (83 FR 16930, 16939). The holdback percentage is determined based on when the payments are made. This holdback amount includes the 2017 BY appeals and 2018 FY sequestration holdback amounts. Amounts held back from FY 2018 resources for the RA program will become available for payment to issuers in FY 2019, unless a RA appeal is pending. In other words, Centers for Medicare & Medicaid Services (CMS) will release the FY 2018 RA holdback after the end of FY 2018 (September 30, 2018) or when all RA appeals for the 2017 BY are resolved in a State market risk pool, whichever is later. If any portion of RA payments for the 2017 BY are made using FY 2019 resources (that is, funds collected during the FY 2019), CMS will hold back 6.2% of RA payments to account for FY 2019 sequestration. These FY 2019 holdback amounts will become available for payment to issuers in FY 2020, unless a RA appeal is pending. When holdback amounts are released, they are not subject to further holdback for appeals or sequestration.

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