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

For 2022, the Facilities for Medicare and Medicaid Products and services is proposing to  use only encounter data in calculating chance adjustment employed to spend Medicare Advantage designs.

The Portion C chance rating would depend fully on encounter data as the supply of MA diagnoses, CMS reported in releasing Portion I of the 2022 Medicare Advantage Advance See.
This represents a improve from the mix for 2021 of 75% of the chance rating calculated applying the 2020 CMS-HCC model and twenty five% of the chance rating calculated applying the older 2017 CMS-HCC model.


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

CMS calculates chance scores applying diagnoses submitted by MA businesses and from Medicare cost-for-service claims. 

Historically, CMS has employed diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS) by MA businesses for the objective of calculating chance scores for payment. 

In recent yrs, CMS started accumulating encounter data from MA businesses, which also contains diagnostic information. CMS started applying diagnoses from encounter data to determine chance scores for CY 2015, and has due to the fact continued to use a mix of encounter and RAPS data-based mostly scores.

Also, for CY 2022, CMS is proposing to discontinue the plan of supplementing diagnoses from encounter data with diagnoses from inpatient data submitted to RAPS for calculating beneficiary chance scores.

THE Much larger Craze

This announcement of Medicare Advantage and Portion D payment methodologies is getting designed somewhere around 3 months before than standard to deliver Medicare Advantage businesses and Portion D sponsors more time to acquire this information into thought as they get ready their bids for 2022.

The before launch will support Medicare Advantage and Portion D designs to superior handle estimating 2022 strategy charges, in gentle of the uncertainty associated with the COVID-19 pandemic.

The Advance See Portion I contains information about Medicare Advantage chance adjustment for 2022 with a sixty-day comment time period. Other changes to payment methodologies for 2022 that are normally contained in the Advance See Portion II only have to have a 30-day comment time period and will be unveiled at a later on time. 

The Medicare Advantage and Portion D payment policies for 2022, talked over in each Portion I and Portion II of the Advance See, will be finalized in the 2022 Charge Announcement printed no later on than April five, 2021.

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