Learn how the Bridge Program applies to NYCE PPO, Large Group, and ASO plan members in 2026.
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Risk Adjustment
What is Risk Adjustment?
Risk adjustment programs are developed and managed by government agencies, as introduced by the Medicare Modernization Act of 2003. These programs were created to serve all eligible members of the public, so that health insurance companies cannot discriminate or purposely insure only a certain demographic of members with a limited range of expected health care costs. Risk adjustment is also critical for ensuring adequate compensation to health insurance companies, so they are able maintain coverage and access to care for beneficiaries likely to incur higher-than-average costs.
Patients
- Identifies patients that would benefit from a treatment plan for their diagnoses.
- Can participate in Care Management programs offered by EmblemHealth.
- Stay engaged in their health.
Providers
- Capture and understand their patients' full burden of illness to better manage health care outcomes.
- Earn additional reimbursement.
EmblemHealth
- Receives proper reimbursement from the Centers for Medicare & Medicaid Services (CMS) to cover the costs derived from the conditions of the patient.
EmblemHealth uses claims coding data to find possible instances of incorrect and/or missing diagnoses that require review, correction, and/or validation. Once these situations are identified, the charts for those members are reviewed.
Providers must submit accurate and specific claims diagnosis coding and maintain detailed medical documentation, as it is critical for risk adjustment. The risk adjustment model relies on ICD-10-CM coding to represent the member’s health status, not just CPT procedure codes. Records are used for validation. Physicians are the main source of information for the risk adjustment model.
Any primary care provider (PCP) who cares for EmblemHealth members enrolled in these products:
- New York State of Health (NYSOH) Marketplace
- Medicare HMO
- Medicaid
JP 71592 4/2026