CMS-10340 Response to 30-day comments 121312

Encounter Data PRA Comments and Responses

Category	Submitter	Submitter Comments	CMS Response	Action
Operational Issues	Aetna	CMS should provide guidance as to what activities will occur in the event the CMS system builds are not completed by 1/3/12	These questions are out of scope as they relate to operational issues. CMS has an extensive process for communicating operational guidance to the plans.	Out of Scope
	Aetna	CMS should provide guidance regarding how plans should populate data fields which may be required under the encounter data process, but may not be populated by the providers.
	Aetna	CMS has not completed system builds or made required decisions for plans to complete testing. CMS should make appropriate accommodations in the early part of 2012 without undue penalties to plans.
PACE	NPA	CMS should recognize distinctions between MA and PACE by pointing out PACE’s implementation delay and clarify the reference to PACE organizations on page nine where we discuss cost plans.	CMS will continue to work with PACE plans to discuss encounter data and how we can accommodate their needs. We will delete the reference to PACE plans on page nine as it is misleading. We will reference the implementation delay for PACE in the PRA.	Update to pages 9, and 15
Cost Plans	Unknown	Page 3 clarifies Encounter Data would be used to verify the accuracy and validity of the costs claimed on Cost Reports. Diagnosis codes do not have any relevance on the cost report. Please clarify.	Response:  Although diagnosis codes might not have a direct correlation to the cost report, we will be directing submitters of encounter data, including Cost HMOs/CMPs, to submit pricing information along with diagnosis codes.  We will make the following edit on page 5 to clarify – the language that we have added is underlined: “Section 1876 Cost HMOs/CMPs are paid reasonable costs actually incurred under the authority in section 1876(h)(3) of the Act. Section 1833 HCPPs are paid reasonable costs under the authority in section 1833(a)(1)(A) of the Act. Reasonable costs are further defined in section 1861(v) of the Act. CMS has the authority to require Cost HMOs/CMPs to submit encounter data under 42 C.F.R. §417.568(b)(1) which requires submission of “adequate cost and statistical data. . .that can be verified by qualified auditors,” and 42 C.F.R. §427.576(b)(2)(iii) which requires “[a]ny other information required by CMS” for purposes of final cost-settlement of payment amounts due. CMS also has the authority to require HCPPs to submit encounter data under 42 C.F.R. §417.806(c) to access “records of the HCPP.. .that pertain to the determination of amounts payable for covered Part B services furnished its Medicare enrollees” and 42 C.F.R. §417.871(b)(2)(iii) to require “other data as specified by CMS” for purposes of final cost-settlement of payment amounts due. In short, in addition to the other stated purposes for collection of encounter data, with respect to §1876 Cost HMOs/CMPs and§1833 HCPPs, data submission requirements included in this encounter data collection will assist us in verifying the accuracy and validity of the costs claimed on Cost Reports.”	Update to page 5
Cost Plans	Unknown	The document talks about CMS reimbursing plans for reasonable costs associated with this initiative. Page 15 says the costs will be recouped through the bidding process. We don't do a bid for the Cost plan. Please clarify whether we are still able to include these costs in the Cost Report?	We have added the following clarifying language to page 15 – the language we have added language is underlined: PAGE 15 For MA and PACE organizations, note that any administrative and/or capital costs incurred will be recouped through the bidding process. Note that in the Supporting Statement we also say: PAGE 15 For cost plans – both §1876 Cost HMOs/CMPs and §1833 HCPPs – although there may be start-up costs, as we have said, we will reimburse the full reasonable cost under our authority in 42 C.F.R. §417.550, including those reasonable start-up costs incurred in 2011. We believe for cost plans this will represent less than $10,000/plan. As there are currently 11 HCPPs and 20 Cost HMOs/CMPs, this would amount to, at most, $310,000 – which costs are all also captured below, under Costs to the Federal Government. PAGE 9:  While the issue of accepting risk is not germane to cost plans, CMS will mitigate impacts on small businesses by reimbursing 100% of the reasonable costs these plans incur in establishing and maintaining encounter data processes needed to compile and transmit information to CMS. CMS will provide payment for the full reasonable cost for gathering and transmitting such data to CMS, consistent with 42 CFR 417.550 et seq. Such full payment for the reasonable costs incurred for gathering and transmitting such data can include reasonable start-up costs incurred in 2011. Consistent with our long-standing policy, we will not reimburse full cost for the creation or enhancement of data systems that can be used for other purposes. Reasonable costs for system’s development or enhancement may, however, be claimed (where appropriate) under normal administrative and general cost reimbursement rules found in §417.564.”	Update to page 15
Misc	Aetna	Aetna asked CMS to consider their comments on the 60 day PRA package and Risk Adjustment Manual.	Out of Scope – The risk adjustment manual is its own document and the original encounter data comments were considered and incorporated as appropriate.	Out of Scope

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