Medicare Advantage Consumer Protection and Transparency Act
This bill generally requires Medicare Advantage organizations to report additional information to the Centers for Medicare & Medicaid Services, including supplemental plan benefits, encounter data, and the number of coverage denials and prior authorization requests. Failure to comply with the bill's requirements may result in payment reductions.
[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9019 Introduced in House (IH)]
<DOC>
117th CONGRESS
2d Session
H. R. 9019
To amend title XVIII of the Social Security Act to require complete and
accurate data set submissions from Medicare Advantage organizations
offering Medicare Advantage plans under part C of the Medicare program
to improve transparency, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 28, 2022
Ms. Porter (for herself, Ms. DeGette, Mr. Doggett, Ms. Schakowsky, Mr.
Pocan, Mr. Grijalva, Mr. Takano, Ms. Castor of Florida, Ms. DeLauro,
and Ms. Jayapal) introduced the following bill; which was referred to
the Committee on Ways and Means, and in addition to the Committee on
Energy and Commerce, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to require complete and
accurate data set submissions from Medicare Advantage organizations
offering Medicare Advantage plans under part C of the Medicare program
to improve transparency, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Advantage Consumer
Protection and Transparency Act''.
SEC. 2. MEDICARE ADVANTAGE SUPPLEMENTAL BENEFITS DATA.
(a) In General.--Section 1852(c) of the Social Security Act (42
U.S.C. 1395w-122(c)) is amended by adding at the end the following new
paragraph:
``(3) Supplemental benefits data.--
``(A) Submissions to secretary.--For each plan year
beginning on or after January 1 of the second year
beginning on or after the date of enactment of this
paragraph, a Medicare Advantage organization offering
supplemental benefits described in subsection (a)(3)
under a Medicare Advantage plan shall submit (or, in
the case of such an organization that contracts with an
entity (such as a third party contractor) to provide
supplemental benefits in connection with such plan,
require under such contract for the entity to submit),
not later than 6 months after the end of the plan year,
to the Secretary, in a clear, accurate, and
standardized form in accordance with subparagraph (B)
complete and accurate (as specified by the Secretary
pursuant to subparagraph (B)) information, at the plan
level and presented by coverage, service, or benefit
type (as applicable), on such benefits offered under
such plan during the plan year, including regarding the
following:
``(i) The type and nature of each
supplemental benefit so offered during such
plan year.
``(ii) The number of Medicare Advantage
eligible individuals enrolled under plan during
such plan year with coverage that enables
access to such benefits.
``(iii) The number of Medicare Advantage
eligible individuals enrolled under the plan
during such plan year who received a service
with respect to each such supplemental benefit
type so offered.
``(iv) The total plan and beneficiary
expenditures made for such supplemental
benefits, with respect to such plan year,
excluding profits, administrative costs, and
other overhead expenses.
``(v) The total beneficiary cost sharing
for supplemental benefits, with respect to such
plan year, reported in total beneficiary
expenditure and as a percentage of total
expenditure.
``(vi) All encounter data related to claims
for supplemental benefits so offered, with
respect to such plan year.
``(vii) All payment data, disaggregated by
contributing payer, related to claims for
supplemental benefits so offered, with respect
to such plan year.
``(viii) Such other information as
specified by the Secretary.
``(B) Regulations.--Not later than July 1 of the
first year beginning on or after the date of the
enactment of this paragraph, for purposes of
subparagraph (A), the Secretary shall, through
rulemaking--
``(i) establish procedures to standardize
the language used in describing supplemental
benefits (including categories of such
benefits) and metrics;
``(ii) establish procedures to standardize
the collection and evaluation of data under
such subparagraph;
``(iii) analyze and publicly report, in
common language, the standardized language to
be used by plans in describing supplemental
benefits (including categories of such
benefits) in any materials intended for
potential consumers, including marketing
materials, plan comparison tools under section
1851(d), and any other materials the Secretary
deems appropriate;
``(iv) specify metrics and methods for
determining whether information submitted under
subparagraph (A) is complete and accurate,
including by requiring such information include
at least comparisons of supplemental benefit
information between encounter records submitted
under 1852(c)(3)(A)(vi), aggregate data
submitted under 1852(c)(3)(A)(i-v), spending
data for types and categories of supplemental
benefits submitted under 1857(e)(4), and
supplemental benefit information submitted
under 1854(a)(6)(A); and
``(v) determine categories or levels of
incompleteness for plans that do not submit
complete encounter data.
In carrying out clause (iv), a Medicare Advantage plan
shall be treated as not submitting complete encounter
data if the Secretary determines the plan has submitted
less than 90 percent of encounter data, including with
respect to the data sources identified in clause
(ii).''.
(b) Penalty for Not Submitting Information.--Section 1853(a)(1) of
the Social Security Act (42 U.S.C. 1395w-23(a)(1)) is amended--
(1) in subparagraph (B)--
(A) in clause (i), by striking ``subparagraphs (F)
and (G)'' and inserting ``subparagraphs (F), (G), and
(J)'';
(B) in clause (ii), by striking ``subparagraphs (F)
and (G)'' and inserting ``subparagraphs (F), (G), and
(J)''; and
(C) in clause (iii), by inserting ``and (if
applicable) under subparagraph (J)'' after
``subparagraph (C)''; and
(2) by adding at the end the following new subparagraph:
``(J) Adjustment for not submitting supplemental
benefit information.--In the case of a Medicare
Advantage plan offered by a Medicare Advantage
organization that, with respect to a plan year
(beginning on or after January 1 of the second year
beginning on or after the date of the enactment of this
subparagraph), has not submitted complete and accurate
information, as required under section 1852(c)(3), for
each month during such plan year (until such month, if
any, during such plan year during which the
organization submits such complete and accurate
information (as determined in accordance with the
metrics and methods specified pursuant to section
1852(c)(3)(B))), the monthly payment amount specified
in clauses (i), (ii), and (iii) of subparagraph (B), as
applicable, shall be reduced by 5 percent of the amount
that would otherwise apply.''.
SEC. 3. MEDICARE ADVANTAGE ENCOUNTER DATA ACCOUNTABILITY.
(a) In General.--Section 1852(c) of the Social Security Act (42
U.S.C. 1395w-122(c)), as amended by section 2, is further amended by
adding at the end the following new paragraph:
``(4) Encounter data accountability.--
``(A) Submissions to secretary.--For each plan year
beginning on or after January 1 of the second year
beginning on or after the date of the enactment of this
paragraph, a Medicare Advantage organization offering a
Medicare Advantage plan shall, in accordance with the
regulations promulgated pursuant to subparagraph (B),
submit to the Secretary, not later than 6 months after
the end of the plan year, complete and accurate (as
specified by the Secretary pursuant to such
regulations) payment data, disaggregated by plan and
beneficiary expenditure, and encounter data for all
encounters covered through benefits under the original
fee-for-service program defined under subsection
(a)(1)(B) occurring during the plan year with respect
to Medicare Advantage eligible individuals enrolled
under such plan during such plan year.
``(B) Regulations.--Not later than July 1 of the
first year beginning on or after the date of the
enactment of this paragraph, for purposes of
subparagraph (A), the Secretary shall, through
rulemaking--
``(i) specify metrics and methods for
determining whether information submitted under
subparagraph (A) is complete and accurate,
which shall include, as applicable, at least
comparisons between--
``(I) encounter records submitted
under this section;
``(II) patient assessment forms for
home health (using information
submitted through the Outcome and
Assessment Information Set instrument
or a successor instrument), skilled
nursing (using information submitted
through the Minimum Data Set tool (or a
successor tool)), and inpatient
rehabilitation services (using
information submitted through the
Inpatient Rehabilitation Facility
Patient Assessment Instrument (or a
successor instrument));
``(III) monthly dialysis indicators
used for risk adjustment;
``(IV) Medicare Provider and
Analysis Review data;
``(V) service utilization data
submitted under section 1854(a)(6)(A);
and
``(VI) any other data source or
method as specified by the Secretary;
and
``(ii) determine categories or levels of
incompleteness for Medicare Advantage plans
that do not submit complete encounter data.
In carrying out clause (ii), a Medicare Advantage plan
shall be treated as not submitting complete encounter
data if the Secretary determines the plan has submitted
less than 90 percent of encounter data, including with
respect to the data sources identified in clause (i).
``(C) Public reporting.--Beginning not later than
July 1 of the second year beginning on or after the
date of the enactment of this paragraph, the Secretary
shall publicly report the data submitted pursuant to
subparagraph (A).''.
(b) Penalty for Not Submitting Information.--Section 1853(a)(1) of
the Social Security Act (42 U.S.C. 1395w-23(a)(1)), as amended by
section 2, is further amended--
(1) in subparagraph (B)--
(A) in clause (i), by striking ``(G), and (J)'' and
inserting ``(G), (J), and (K)'';
(B) in clause (ii), by striking ``(G), and (J)''
and inserting ``(G), (J), and (K)''; and
(C) in clause (iii), by striking ``subparagraph
(J)'' and inserting ``subparagraphs (J) and (K)''; and
(2) by adding at the end the following new subparagraph:
``(J) Adjustment for not submitting encounter
data.--
``(i) In general.--In the case of a
Medicare Advantage plan offered by a Medicare
Advantage organization that, with respect to a
plan year (beginning on or after January 1 of
the second year beginning on or after the date
of the enactment of this subparagraph), has not
submitted any encounter information under
section 1852(c)(4), for each month during such
plan year (until such month, if any, during
such plan year during which the organization
submits such information), the monthly payment
amount specified in clauses (i) and (ii) of
subparagraph (B) shall be reduced by 10 percent
of the amount that would otherwise apply.
``(ii) Reduction for incomplete data
submitted.--In the case of a Medicare Advantage
plan offered by a Medicare Advantage
organization that, with respect to a plan year
(beginning on or after January 1 of the second
year beginning on or after the date of the
enactment of this subparagraph), has submitted
encounter information, as required under
section 1852(c)(4), but such information is not
complete or is not accurate, as required under
such section, for each month during such plan
year (until such month, if any, during such
plan year during which the organization submits
such complete and accurate information), the
monthly payment amount specified in clauses
(i), (ii), and (iii) of subparagraph (B), as
applicable, shall be reduced by a percent
specified by the Secretary (not to exceed 5
percent) of the amount that would otherwise
apply. Such percent specified by the Secretary
shall be based on the percentage of information
missing in the submission and determined
pursuant to rulemaking.
``(iii) Process.--In applying the
reductions under this subparagraph, the
Secretary--
``(I) shall provide public
justification for any percent reduction
applied pursuant to clause (ii),
including data used to arrive at the
determination of the percent so
applied;
``(II) may authorize an internal
entity or contract with an external
entity to assist with carrying out
subclause (I) and determining any
percent reduction to be applied under
clause (ii); and
``(III) shall establish a mechanism
for Medicare Advantage organizations to
appeal determinations under this
subparagraph, with respect to such
organization.
``(iv) Collection of data through medicare
administrative contractors.--The Secretary
shall implement a mechanism requiring direct
submission of provider claims to Medicare
Administrative Contractors--
``(I) for Medicare Advantage plans
that submit incomplete or inaccurate
encounter information under this
subparagraph for 2 consecutive years;
and
``(II) in the case that the
Secretary finds that more than 5
percent of Medicare Advantage plans
submitted incomplete or inaccurate
information for three consecutive
years, beginning with the subsequent
year, for all Medicare Advantage
plans.''.
(c) MedPAC Report.--Not later than 3 years after the date on which
information is first required to be submitted pursuant to paragraph (3)
of section 1852(c) of the Social Security Act (42 U.S.C. 1395w-122(c)),
as added by section 2 (a), and paragraph (4) of such section 1852(c),
as added by subsection (a), the Medicare Payment Advisory Commission
shall submit to Congress a report on such information that includes a
descriptive analysis of any information reported pursuant to such
paragraph.
SEC. 4. DATA ON COVERAGE DENIALS AND PRIOR AUTHORIZATION REQUIREMENTS.
(a) In General.--Section 1852(c) of the Social Security Act (42
U.S.C. 1395w-22(c)), as amended by sections 2 and 3, is further amended
by adding at the end the following new paragraph:
``(5) Data on coverage denials and prior authorization
requirements.--
``(A) In general.--For each plan year beginning on
or after January 1 of the second year beginning on or
after the date of the enactment of this paragraph, with
respect to applicable benefits described in subsection
(a)(1), subsection (a)(3), and section 1860D-2, a
Medicare Advantage organization offering a Medicare
Advantage plan shall, in addition to any applicable
information described in a previous paragraph, submit,
not later than 6 months after the end of the plan year,
to the Secretary the following data, at the plan level
and presented by coverage, service, or benefit type (as
applicable), with respect Medicare Advantage eligible
individuals enrolled under such plan during such plan
year:
``(i) The number of claims denied,
presented by reason for the denial.
``(ii) The number and type of claims
requiring prior authorization or
precertification.
``(iii) The average period between the
initial submission of a claim for approval and
the delivery of care.
``(iv) The number and percentage of
coverage denials appealed by service type.
``(v) The number and percentage of prior
authorizations or precertifications appealed.
``(vi) The number of favorable decisions
that overturned the initial coverage
determination upon appeal.
``(vii) The average period between the
formal initiation of appeal proceedings and
final determination.
``(viii) Total number and percentage of
conversions of inpatient stays to outpatient
and observation status.
``(ix) Information on each prior
authorization or precertification episode,
including the Medicare Advantage contract
number, beneficiary Medicare ID, national
provider identifier, provider tax
identification number, Healthcare Common
Procedure Coding System codes and modifiers,
initial date of receipt, date of initial
decision, action taken by the plan, denial code
(if applicable), initial appeal date (if
applicable), and final appeal decision date (if
applicable).
``(x) Such other information as specified
by the Secretary.
``(B) Denial codes and additional data elements.--
Not later than January 1 of the second year beginning
on or after the date of the enactment of this
paragraph, for purposes of subparagraph (A)(ix), the
Secretary shall establish--
``(i) denial code categories and
definitions and provide to Medicare Advantage
plans guidance on such categories and
definitions; and
``(ii) additional standardized data
elements, as appropriate.''.
(b) Further Disclosures.--Section 1851(d)(4) of the Social Security
Act (42 U.S.C. 1395w-21(d)(4)) is amended by adding at the end the
following new subparagraph:
``(F) Coverage denials and prior authorizations.--
Information submitted by the plan under section
1852(c)(5), with respect to such year.''.
SEC. 5. QUALITY MEASURES.
(a) In General.--Section 1852(e)(3)(A) of the Social Security Act
(42 U.S.C. 1395w-22(e)(3)(A)) is amended--
(1) in clause (i), by striking ``and subject to
subparagraph (B)'' and inserting ``and subject to clause (v)
and subparagraph (B)''; and
(2) by adding at the end the following new clause:
``(v) Plan level data.--For each plan year
beginning on or after January 1 of the second
year beginning on or after the date of the
enactment of this clause, subject to section
1853(o)(6), data submitted under this
subparagraph shall be at the plan level in
addition to the contract level.''.
(b) Application to Star Rating System.--Section 1853(o)(4)(A) of
the Social Security Act (42 U.S.C. 1395w-23(o)(4)(A)) is amended by
adding at the end the following new sentence: ``For each plan year
beginning on or after January 1 of the second year beginning on or
after the date of the enactment of the Medicare Advantage Consumer
Protection and Transparency Act, subject to paragraph (6), the
Secretary shall require reporting of data under section 1852(e) for,
and apply under this subsection, quality measures at the plan level in
addition to at the contract level.''.
SEC. 6. PROVIDER NETWORK INFORMATION.
(a) In General.--Section 1851(d)(5) of the Social Security Act (42
U.S.C. 1395w-21(d)(5)) is amended by adding at the end the following:
``For each plan year beginning on or after January 1 of the second year
beginning on or after the date of the enactment of the Medicare
Advantage Consumer Protection and Transparency Act, the Secretary shall
ensure such Internet site includes complete and accurate information
(to be updated at least quarterly) on providers of services and
suppliers participating in the networks of Medicare Advantage plans and
a portal that enables plans to update information on such site on the
providers of services and suppliers participating in the networks of
such plans, including any changes in such networks and whether such
providers and suppliers are accepting new patients.''.
(b) Disclosure by Plans.--Section 1851(d)(4) of the Social Security
Act (42 U.S.C. 1395w-21(d)(4)), as amended by section 4(b), is further
amended by adding at the end the following new subparagraph:
``(G) Provider network information.--For each plan
year beginning on or after January 1 of the second year
beginning on or after the date of the enactment of this
subparagraph, accurate information that is submitted in
a machine readable format and that identifies all
providers of services and suppliers participating in
the network of the plan, including all changes to such
network that occur during the plan year, and whether
such providers and suppliers are accepting new
patients.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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