Risk Adjustment Toolkit

Lines and dots illustration. Tools to Help ACA Marketplace Vendors Maximize Risk Adjustment Returns.
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We offer a set of open-code, SQL based tools to help ensure you are maximizing your return on your ACA Risk Adjustment processes.

These tools can help you maximize your risk adjustment returns and ensure you are capturing the full value of the risk you have taken on. You’ve invested in your risk adjustment program – these tools help to make sure you are getting the most out of it.

Lines and dots illustration. Tools to Help Risk Adjustment in the ACA Markets.

Products and Pricing

DIY Risk Adjustment Model (SQL)

For all years. Customers who license any other module will receive 2 hours of implementation / technical assistance for the DIY model.

FREE

Member Level Profitability Tool

Summarizes your premium, claims, and risk adjustment data at the member level to allow you to analyze specific population groups.

Pricing

  • $20,000 per year for the first state

  • $10,000 for each additional state
    (includes member level risk transfer calculator tool)

Leading EDGE:
Claims Value Calculator

Finds denied / pending claims that if paid would provide additive HCCs / risk score value to help you prioritize your operational work flows.

Pricing

  • $15,000 per year for the first state

  • $5,000 per year for each additional state

Risk Score Triangle Calculator

Develops a lag triangle of your risk score development to allow you to study changes in completion patterns to help you better understand and predict your risk score changes throughout the year.

Pricing

  • $2,500 per year
    (no additional charge for additional states)

Member Level Risk Adjustment Transfer Calculator

Calculates a rough estimate of risk transfer at the member level to help you look at your MLR in a more granular way.

Pricing

  • $7,500 per year for the first state

  • $2,500 per year for each additional state

EDGE XML Conversion Tool

Converts inbound and outbound EDGE XMLs into SQL tables to allow you to analyze your EDGE server submissions and ensure the EDGE server and your data warehouse are aligned.

Pricing

  • $15,000 per year (no additional charge for additional states)

The entire toolkit can also be purchased as a bundle starting at $30,000 per year for single state issuers. The bundle also includes 5 hours of implementation support and up to 2 hours a month of consulting support. Bundling the entire toolkit provides tools and support valued at over $50,000 at a fraction of the cost. Pricing is for health plans with up to 100,000 members. Additional PMPM charges of up to $0.05 PMPM apply above 100,000 members due to third party licensing expenses.