3 Alaska Admin. Code § 31.535

Current through December 21, 2024

Section 3 AAC 31.535 - Annual true-up

(a) The association shall establish a true-up process with respect to a calendar year to reflect adjustments made in establishing the final accounting for that calendar year, including crediting of premiums received with respect to risk ceded after the end of the calendar year and retroactive reductions or other adjustments in reimbursements necessary to prevent a deficit in the fund for that calendar year and to prevent a windfall to an insurer as a result of third party recoveries, recovery of overpayments, commercial reinsurance recoveries, or risk adjustments made under 42 U.S.C. 18063 (Sec. 1343 of the Patient Protection and Affordable Care Act, P.L. 111-148 ). The true-up must occur after April 30 following the calendar year to which it relates.

(b) With respect to the risk adjustment transfers as determined by the United states Department of Health and Human Services, Centers for Medicine and medicaid Services, Center for Consumer Information and Insurance Oversight (CCIIO),

(1) the director or the director's designee will review the risk adjustment transfers to determine the impact of the ceding of risk to the program;

(2) the review will occur not later than 60 days after publication of the notice of final risk adjustment transfers by Center for Consumer Information and Insurance Oversight;

(3) the director or director's designee will notify a health care insurer of the amount of any risk adjustment transfer it received that does not accurately reflect benefits provided under the program and

(A) the health care insurer shall pay that amount to the program not later than 30 days after receipt of the notice from the director or the director's designee; and

(B) as appropriate, the director or the director's designee will refund that amount to the health care insurer or insurers that made the federal risk adjustment payment; and

(4) to facilitate the true-up process, a health care insurer shall submit to the director or the director's designee, in a form and manner determined by the director or the directors' designee, all data requested by the director in a data call in March of the year following the year to which the risk adjustment applies.

3 AAC 31.535

Eff. 2/2/2013, Register 205; am 12/22/2016, Register 220, January 2017; am 11/1/2018,Register 228, January 2019

Authority:AS 21.06.090

AS 21.55.040

AS 21.55.220

AS 21.55.400

AS 21.55.430