White paper: Commercial risk adjustment updates to prepare for in 2026

Written by Amanda Liu | May 22, 2025 5:46:48 PM

First introduced in 2014 as part of the Affordable Care Act (ACA), commercial risk adjustment aims to create a level playing field for plans serving members with higher-than-average risk scores and needs. This is accomplished through a risk transfer formula enabling monetary transfers from lower-risk plans to higher-risk plans within the same market.

For the 2023 benefit year, the absolute value of all transfers totaled nearly $20.6 billion, meaning $10.3 billion was charged to plans with lower risk scores and $10.3 billion in payments was received by plans with higher risk scores. 

As Marketplace plans optimize their risk adjustment programs to ensure successful execution in 2026, read Cotiviti’s new white paper as we highlight strategies to address changes introduced by the HHS Notice of Benefit and Payment Parameters for 2026, including:

Coverage design
Risk Adjustment Data Validation (RADV) audit methodology
HHS risk adjustment user fee and medical loss ratio (MLR) regulations

Dive in as we explore strategies and actions that will set up Qualified Health Plans (QHPs) for success in each of these areas, with a focus on deploying analytics, provider education, member engagement, and audit strategies.

With preparation, QHPs can better position themselves to improve risk score accuracy, optimize their programs, and help ensure financial stability as 2026 approaches. Don’t miss this opportunity to strengthen your risk adjustment program and better prepare for future audits.

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