Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a)

Crosswalk for Supporting Statement for Paperwork Reduction Act Submission:
Part C Medicare Advantage Reporting Requirements and
Supporting Regulations in 42 CFR 422.516(a)
CMS-10261, OCN 0938-1054—
30-Day Comment Period
Please note that a detailed discussion of the associated burden changes is set out in section 15 of
Supporting Statement A.

The proposed changes in this ICR are as follows: Three reporting sections, Organization
Determinations/Reconsiderations, Special Needs Plans Care Management, and
Enrollments/Disenrollments, were updated to include additional data elements. For most
reporting sections with a data due date of February 28, the data due date was changed to the last
Monday in February, For Part C Grievances, Sponsor Oversight of Agents, and Employer Group
Plan Sponsors, the data due dates were changed to the first Monday in February. The due date
for Enrollment/Disenrollment was changed to the last Monday of August and February. This
“staggering” of data due dates is proposed so that the reporting load would be more manageable
in 2016 than it was in 2015 for CMS/HPMS. Also, having the data due date fall on February 28,
as it was in the past, introduced problems when February 28 was on a weekend or when it
occurred in a leap year. By listing the last Monday in February, this problem is eliminated. This
changing of due dates is not expected to impact burden in terms of hours or costs. The final set of
proposed changes is the addition of two reporting sections: Rewards and Incentives Program and
Mid-Year Network Changes.
#6 Organization Determinations and Reconsiderations (see below for added data elements)
Data elements for this reporting section are contained in Table 1. Two new data elements would
be added: data element 6.10, Number of Requests for Organization Determinations—Dismissals,
and data element 6.20, Number of Requests for Reconsiderations—Dismissals. These additions
will fill user needs for data on dismissals and make this reporting section more consistent with a
similar reporting section in Part D, Coverage Determinations and Redeterminations.
Table 1: Data Elements for Organization Determinations/Reconsiderations Reporting Section
Element
Number
6.1
6.2
6.3
6.4
6.5

Data Elements for Organization Determinations/Reconsiderations
Total Number of Organization Determinations Made in Reporting Time Period Above
Of the Total Number of Organization Determinations in 6.1, Number Processed Timely
Number of Organization Determinations – Fully Favorable (Services)
Number of Organization Determinations – Fully Favorable (Claims)
Number of Organization Determinations – Partially Favorable (Services)
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6.6
6.7
6.8
6.9
6.10*
6.11
6.12
6.13
6.14
6.15
6.16
6.17
6.18
6.19
6.20*
6.21

Number of Organization Determinations – Partially Favorable (Claims)
Number of Organization Determinations – Adverse (Services)
Number of Organization Determinations – Adverse (Claims)
Number of Requests for Organization Determinations - Withdrawn
Number of Requests for Organization Determinations - Dismissals
Total number of Reconsiderations Made in Reporting Time Period Above
Of the Total Number of Reconsiderations in 6.10, Number Processed Timely
Number of Reconsiderations – Fully Favorable (Services)
Number of Reconsiderations – Fully Favorable (Claims)
Number of Reconsiderations – Partially Favorable (Services)
Number of Reconsiderations – Partially Favorable (Claims)
Number of Reconsiderations – Adverse (Services)
Number of Reconsiderations – Adverse (Claims)
Number of Requests for Reconsiderations - Withdrawn
Number of Requests for Reconsiderations - Dismissals
Total number of reopened (revised) decisions, for any reason, in Time Period Above
For each case that was reopened, the following information will be uploaded in a data file:

6.22
6.23
6.24
6.25

Contract Number
Plan ID
Case ID
Date of original disposition

6.26
6.27
6.28
6.29
6.30
6.31

Original disposition (Fully Favorable; Partially Favorable or Adverse)
Case level (Organization Determination or Reconsideration)
Date case was reopened
Reason(s) for reopening (Clerical Error, New and Material Evidence, or Other)
Date of reopening disposition (revised decision)
Reopening disposition (Fully Favorable; Partially Favorable, Adverse or Pending)
* Indicates new data element.

#13: Special Needs Plans (SNPs) Care Management
SNPs will now also report the enrollee initial health risk assessment (HRA), and the annual
reassessment refusals that must be documented in their internal records. SNPs will also report
when the plans are unable to reach an enrollee to perform an initial HRA or an annual
reassessment. The SNP must document in its internal records that the enrollee did not respond to
at least 3 phone calls and a follow up letter, all soliciting participation in the HRA. The data
elements are listed below:

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Reporting
section
13. SNPs Care
Management

Organization Types
Required to Report
SNP PBPs under the
following types:
01 – Local CCP
11 – Regional CCP
15 – RFB Local CCP

Report
Freq./
Level
1/Year
PBP

Report
Period
(s)
1/112/31

Data Due date (s)

2/28 of following
year

Organizations should
exclude 800 series
plans if they are SNPs.
Data elements reported under this reporting section are:
D.E
No.
13.1

Data Element
(D.E.)
Number of new
enrollees.

Inclusions

Exclusions

New enrollees are defined with respect
to the "90-day rule." The initial health
risk assessment is expected to be
completed within 90 days (before or
after) the effective date of enrollment
which must be continuous for that
period. The member could have initially
enrolled as early as 90 days prior to the
measurement year (enrolled as early as
10/3 of the previous year) and would
still be eligible in the current
measurement year as of 1/1 if no initial
HRA had been performed prior to 1/1.
For the purposes of this reporting,
members enrolled continuously for
more than 90 days in the same plan
without completing an initial HRA are
reported as being eligible for an initial
HRA (data element 13.1=1) but not
having received an initial HRA (data
element 13.3=0—refer to data element
13.3 below). After that 90-day period,
members are no longer reported as
eligible for an initial HRA in the same

Members with a
documented initial HRA
under that plan prior to
the measurement year.
Excludes new members
who disenrolled from the
plan within 90 days
before or after the
effective date of
enrollment, if they did
not complete an initial
HRA prior to
disenrolling. Excludes
members who receive an
initial HRA and remain
continuously enrolled
under a MAO whose
contract was part of a
consolidation or merger
under the same legal
entity during the
member’s continuous
enrollment, where the
consolidated SNP is still
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13.2

13.3

Number of
enrollees eligible
for an annual
health risk
reassessment
(HRA)

plan but are reported as eligible for a
“reassessment HRA” in that same plan.
If a member disenrolls from one plan
and enrolls in another plan, that
member is reported as eligible for an
initial HRA anytime during the initial
period of 90 days before or after the
effective enrollment date.
Report all members in the same health
plan who:

1. Completed a reassessment HRA
within 365 days of their last HRA
(initial or reassessment).
2. Were enrolled for 365 days
continuously after their initial HRA
or their last reassessment HRA and
did not complete a reassessment
HRA within 365 days
3. Did not complete an initial HRA
within 90 days before or after the
effective date of enrollment and
reached the threshold of 365 days of
continuous enrollment after initial
enrollment without completing a
reassessment HRA.
Number of initial Initial HRAs performed on new
HRAs performed enrollees (as defined above in data
on new enrollees. element 13.1) within 90 days before or
after effective date of enrollment. The
HRA must be completed between
1/1and 12/31 of the measurement year.

13.4

Number of initial Initial HRAs not performed on new
HRA refusals*
enrollees within 90 days (before or
after) effective date of enrollment due
to enrollee refusal.

13.5

Number of initial
HRAs where
SNP is unable to
reach new
enrollees*

Initial HRAs not performed on new
enrollees within 90 days before or after
the effective date of refusal due to SNP
unable to reach new enrollees

under the same MOC as
the enrollee’s previous
SNP.

Enrollees who did not
reach a threshold of
continuous enrollment in
the same health plan for
at least 365 days after
their last HRA and did
not complete a
reassessment HRA in
that plan within the 365
day timeframe as
required.

Excludes reporting on
number of completed
initial HRAs if there is
no documentation on
enrollee refusal.
Excludes reporting on
number of completed
initial HRAs where the
SNP has less than 3
phone calls and a follow
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up letter – during the 90
day period (before or
after) the initial
assessment. Excludes
reporting on initial
HRAs if there is no
documentation that the
enrollee did not respond
to SNP solicitation.to
participate in the initial
HRA
13.6

13.7

Number of
annual
reassessments
performed.

Number of
annual
reassessments
refusals*

Number of annual reassessments
performed on enrollees eligible for a
reassessment (during the measurement
year as defined in element 13.2 above).
This includes:
Reassessments performed within 365
days of last HRA (initial or
reassessment HRA) on eligible
enrollees. It also includes “first time”
assessments occurring within 365 days
of initial enrollment on individuals
continuously enrolled up to 365 days
from enrollment date without having
received an initial HRA.
Annual reassessments not performed on
an enrollee due to enrollee refusal.

Excludes reporting on
number of completed
reassessments if there is
no documentation on
enrollee refusal.

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13.8

Number of
annual
reassessments
where SNP is
unable to reach
enrollee*

Annual reassessments not performed on
an enrollee where SNP is unable to
reach enrollees.

Excludes reporting on
number of completed
reassessments where the
SNP documents that it
has less than 3 phone
calls, and a follow up
letter. Excludes
reporting on enrollees if
there is no
documentation that the
enrollee did not respond
to SNP solicitation to
participate in the initial
HRA.

*Indicates new data element.

#14: Enrollment/Disenrollment (see below for added data elements)
CMS provides guidance for MAOs and Part D sponsors’ processing of enrollment and
disenrollment requests. For Part C reporting, this involves only 1876 cost contracts with no Part
D. (For other organization types, reporting is under the appropriate section in the Part D
reporting requirements.) Under enrollment, only data elements A-I are reported under Part C. In
2014, there were only 10 contracts reporting enrollment/disenrollment for this reporting section
under Part C.
Four new data elements would be added under disenrollment—data elements D-G. These data
elements would report the number of involuntary disenrollments for failure to pay plan premium
in the specified time period, of these, the number of disenrolled individuals who submitted a
timely request for reinstatement for Good Cause, of these, the number of favorable Good Cause
determinations, and, of these, the number of individuals reinstated.
1. Enrollment:
A. The total number of enrollment requests (i.e., requests initiated by the beneficiary or
his/her authorized representative) received in the specified time period. Do not include
auto/facilitated or passive enrollments, rollover transactions or other enrollments
effectuated by CMS.
B. Of the total reported in A, the number of enrollment requests complete at the time of
initial receipt (i.e. required no additional information from applicant or his/her authorized
representative).
C. Of the total reported in A, the number of enrollment requests that required requests for
additional information.
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D. Of the total reported in A, the number of enrollment requests denied due to the Sponsor’s
determination of the applicant’s ineligibility to elect the plan (e.g. individual not having a
valid enrollment period).
E. Of the total reported in C, the number of incomplete enrollment requests received that are
completed within established timeframes.
F. Of the total reported in C, the number of enrollment requests denied due to the applicant
or his/her authorized representative not providing information to complete the enrollment
request within established timeframes.
G. Of the total reported in A, the number of paper enrollment requests received.
H. Of the total reported in A, the number of telephonic enrollment requests received (if
offered).
I. Of the total reported in A, the number of internet enrollment requests received via plan or
third-party affiliated website.
J. Of the total reported in A, the number of Online Enrollment Center (OEC) enrollment
requests received. For stand-alone prescription drug plans (PDPs) only:*
K. Of the total reported in A, the number of enrollment requests effectuated by sales persons
(as defined in Chapter 3 of the Medicare Managed Care Manual). (This does not apply to
Part C or 1876 cost plans.)*
L. Of the number reported in A, the number of enrollment transactions submitted using the
SEP Election Period code "S" related to creditable coverage.*
M. Of the number reported in A, the number of enrollment transactions submitted using the
SEP Election Period code "S" related to SPAP. (This does not apply to Part C or 1876
cost plans.)*
N. For stand-alone prescription drug plans (PDPs) only: Of the number reported in A, the
number of enrollment transactions submitted using the SEP Election Period code “S”
related to SPAP (This does not apply to Part C or 1876 cost plans.)*
O. Of the number reported in A, the number of enrollment transactions submitted using the
SEP Election Period Code “S” for individuals affected by a contract nonrenewal, plan
termination or service area reduction.*
*Indicates not reported under Part C.

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2. Disenrollment:
A. The total number of voluntary disenrollment requests received in the specified time
period.
B. Of the total reported in A, the number of disenrollment requests complete at the time of
initial receipt (i.e. required no additional information from enrollee or his/her authorized
representative).
C. Of the total reported in A, the number of disenrollment requests denied by the Sponsor
for any reason.
D. The total number of involuntary disenrollments for failure to pay plan premium in the
specified time period.**
E. Of the total reported in D, the number of disenrolled individuals who submitted a timely
request for reinstatement for Good Cause.**
F. Of the total reported in E, the number of favorable Good Cause determinations.**
G. Of the total reported in F, the number of individuals reinstated.**
** Indicates new data element.

# 15 Reporting Section: Rewards and Incentives Program (new reporting section)
CMS has added a new regulation at 42 CFR §422.134 that permits MA organizations to offer
one or more Rewards and Incentives Program to currently enrolled members. Plans have a
choice in whether or not they offer a Rewards and Incentives Program(s), but if they do, they
must comply with the regulatory requirements set forth at §422.134. CMS needs to collect
Rewards and Incentives Program data in order to track which MA organizations are offering
such programs and how those programs are structured. This will inform future policy
development and allow CMS to determine whether programs being offered adhere to CMS
standards and have proper beneficiary protections in place. Based on 60-day comments, this
reporting section no longer requires 1876 cost plans to report.
The data elements remain as follows:
15.1 Do you have a Rewards and Incentives Program(s)? (“0” = “No”; “1” = “Yes”)
If yes, please list each individual Rewards and Incentives Program you offer and provide
information on the following:
15.2 What health related services and/or activities are included in the program? Text
15.3 What reward(s) may enrollees earn for participation? Text
15.4 How do you calculate the value of the reward? Text
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15.5 How do you track enrollee participation in the program? Text
15.6 How many enrollees are currently enrolled in the program? Enter _ _ _ _ _ _ _
15.7 How many rewards have been awarded so far? Enter _ _ _ _

#16 Reporting Section: Mid-Year Network Changes (new reporting section)
CMS is increasing its oversight and management of MAOs’ network changes in order to ensure
that changes made during the plan year do not result in inadequate access to care for enrolled
beneficiaries and that MAOs are provided timely and appropriate notification to providers and
enrollees. The data collected in this new measure will provide CMS with a better understanding
of how often Medicare Advantage Organizations (MAOs) undergo mid-year network changes
and how many enrollees are affected. Collecting these data will help to inform CMS in
determining how broadly to use the new Network Management Module (NMM) in the Health
Plan Management System (HPMS) to verify that plans’ networks meet CMS network adequacy
standards. In addition, responses from MAOs will enhance CMS’ ability to improve network
change protocol.

Legal Basis:
In accordance with 42 CFR § 422.112 (a)(1)(i), each MA organization under Part C Medicare
that offers a coordinated care plan is required to “maintain and monitor a network of appropriate
providers that is…sufficient to provide adequate access to covered services to meet the needs of
the population served.”

Based on 60-day comments, there are now 53 data elements instead of 13. The proposed data
elements, all reported at the contract level, are now:

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Data Elements (at the contract level):

Element
Number
16.1

16.2

16.3

16.4

16.5-16.13

16.14-16.22

16.23-16.31

16.32-16.40

16.41
16.42

Data Elements for Provider Network Adequacy Measure
Total number of PCPs in network on first day of reporting period,
including the following PCP types - General Practice, Family Practice,
Internal Medicine, Geriatrics, Primary Care- Physician Assistants,
Primary Care-Nurse Practitioners
Total number of PCPs in network terminated during the reporting
period, including the following PCP types - General Practice, Family
Practice, Internal Medicine, Geriatrics, Primary Care- Physician
Assistants, Primary Care-Nurse Practitioners
Total number of PCPs added to network during reporting period,
including the following PCP types - General Practice, Family Practice,
Internal Medicine, Geriatrics, Primary Care- Physician Assistants,
Primary Care-Nurse Practitioners
Total number of PCPs in network on last day of reporting period,
including the following PCP types - General Practice, Family Practice,
Internal Medicine, Geriatrics, Primary Care- Physician Assistants,
Primary Care-Nurse Practitioners
Number of specialists/facilities in network on first day of reporting
period by specialist/facility type –Cardiologist (16.5), Endocrinologist
(16.6), Oncologist (16.7), Ophthalmologist (16.8), Pulmonologist
(16.9), Rheumatologist (16.10), Urologist (16.11), Acute Inpatient
Hospitals (16.12), Skilled Nursing Facilities (16.13)
Number of specialists/facilities in network terminated during the
reporting period by specialist/facility type– Cardiologist (16.14),
Endocrinologist (16.15), Oncologist (16.16), Ophthalmologist (16.17),
Pulmonologist (16.18), Rheumatologist (16.19), Urologist (16.20),
Acute Inpatient Hospitals (16.21), Skilled Nursing Facilities (16.22)
Number of specialists/facilities added during reporting period by
specialist/facility type - Cardiologist (16.23), Endocrinologist (16.24),
Oncologist (16.25), Ophthalmologist (16.26), Pulmonologist (16.27),
Rheumatologist (16.28), Urologist (16.29), Acute Inpatient Hospitals
(16.30), Skilled Nursing Facilities (16.31)
Number of specialists in network on last day of reporting period by
specialist/facility type- Cardiologist (16.32), Endocrinologist (16.33),
Oncologist (16.34), Ophthalmologist (16.35), Pulmonologist (16.36),
Rheumatologist (16.37), Urologist (16.38), Acute Inpatient Hospitals
(16.39), Skilled Nursing Facilities (16.40)
Total number of enrollees on first day of reporting period
Total number of enrollees affected by termination of PCPs during

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16.43-16.51

16.53

reporting period
Total number of enrollees affected by termination of
specialists/facilities by specialist/facility type during reporting periodCardiologist (16.44), Endocrinologist (16.45), Oncologist (16.46),
Ophthalmologist (16.47), Pulmonologist (16.48), Rheumatologist
(16.49), Urologist (16.50), Acute Inpatient Hospitals (16.51), Skilled
Nursing Facilities (16.52)
Total number of enrollees on last day of reporting period

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