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.
Notes
Authority:AS 21.06.090
AS 21.55.040
AS 21.55.220
AS 21.55.400
AS 21.55.430
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