CMS proposes using only encounter data for Medicare Advantage risk adjustment and payment

Jannie Delucca

For 2022, the Centers for Medicare and Medicaid Services is proposing to  use only come across details in calculating threat adjustment applied to pay out Medicare Gain designs.

The Part C threat rating would rely solely on come across details as the resource of MA diagnoses, CMS mentioned in releasing Part I of the 2022 Medicare Gain Progress Discover.
This signifies a transform from the blend for 2021 of seventy five% of the threat rating calculated using the 2020 CMS-HCC product and 25% of the threat rating calculated using the older 2017 CMS-HCC product.

WHY THIS Matters

The transform is demanded by the 21st Century Cures Act. 

CMS calculates threat scores using diagnoses submitted by MA businesses and from Medicare charge-for-service statements. 

Traditionally, CMS has applied diagnoses submitted into CMS’ Risk Adjustment Processing Program (RAPS) by MA businesses for the objective of calculating threat scores for payment. 

In modern yrs, CMS began gathering come across details from MA businesses, which also features diagnostic details. CMS began using diagnoses from come across details to compute threat scores for CY 2015, and has due to the fact continued to use a blend of come across and RAPS details-dependent scores.

Also, for CY 2022, CMS is proposing to discontinue the coverage of supplementing diagnoses from come across details with diagnoses from inpatient information submitted to RAPS for calculating beneficiary threat scores.

THE Larger Craze

This announcement of Medicare Gain and Part D payment methodologies is remaining designed approximately three months earlier than usual to give Medicare Gain businesses and Part D sponsors more time to choose this details into thought as they prepare their bids for 2022.

The earlier release will assist Medicare Gain and Part D designs to greater address estimating 2022 strategy charges, in gentle of the uncertainty associated with the COVID-19 pandemic.

The Progress Discover Part I features details about Medicare Gain threat adjustment for 2022 with a sixty-day remark interval. Other adjustments to payment methodologies for 2022 that are typically contained in the Progress Discover Part II only demand a thirty-day remark interval and will be released at a later time. 

The Medicare Gain and Part D payment policies for 2022, mentioned in the two Part I and Part II of the Progress Discover, will be finalized in the 2022 Charge Announcement printed no later than April five, 2021.

Twitter: @SusanJMorse
E mail the author: [email protected]

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