Dec 1 -- The Centers for Medicare & Medicaid Services (CMS) invites public comment by January 30, 2024 regarding the Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations.
Section 1853(a)(3)(B) of the Act directs CMS to require MA organizations and eligible organizations with risk-sharing contracts under 1876 to “submit data regarding inpatient hospital services ... and data regarding other services and other information as the Secretary deems necessary” in order to implement a methodology for “risk adjusting” payments made to MA organizations and other entities. Risk adjustments to enrollee monthly payments are made in order to take into account “variations in per capita costs based on [the] health status” of the Medicare beneficiaries enrolled in an MA plan.
CMS uses encounter data to develop individual risk scores for risk adjusted payment to MA organizations, PACE organizations, and MMPs. Starting with Payment Year (PY) 2016, CMS began to blend risk scores calculated with Risk Adjustment Processing Data and Medicare Fee- For-Service (FFS) data with risk scores calculated with encounter data and FFS data, for risk scores calculated under both the CMS–HCC and the RxHCC models. In PY 2022, we will move to calculating risk scores under both the CMS–HCC and the RxHCC models using 100 percent of the risk score calculated using encounter data and FFS data.
All organizations required to submit encounter data use an electronic connection between the organization and CMS to submit encounter data and to receive information in return. CMS collects the data from MA organizations, 1876 Cost Plans, MMPs and PACE organizations in the X12N 837 5010 format for professional, DME, and institutional, and dental services or items provided to MA enrollees.
Frequency: Daily
Number of Respondents: 284
Total Annual Responses: 1,467,645,179
Medicare-Medicaid Plan (MMP) Encounter Data Reporting:
https://www.cms.gov/medicare/medicaid-coordination/plans/mmp-encounter-data-reporting
Draft data collection instruments and technical documentation:
https://www.cms.gov/regulations-and-guidance/legislation/paperworkreductionactof1995/pra-listing-items/cms-10340
FRN:
https://www.federalregister.gov/d/2023-26449 #2
