Response to Comments (30-day)

Appendix B: Comments and Responses for 30-day Comment Period CMS-10261

Commenter: 1jz-8lrx-yfor Central Health Plan of California

COMMENT:

For Mid-Year Changes, the Data Elements grid indicates that Element Numbers 16.43 – 16.51 includes data measures for total number of enrollees affected by termination of specialists/facilities by specialist/facility type, but the actual data element description states:

• Total number of enrollees affected by termination of specialists/facilities by specialist/facility type during reporting period-Cardiologist (16.44), Endocrinologist (16.45), Oncologist (16.46).

Therefore, data element 16.43 appears to be missing.

CMS Response:

This is correct. The table has been revised.

COMMENT:

The requirements indicate that “Affected enrollees are those beneficiaries who were assigned to a terminated PCP or who were treated by a terminated specialist or received care in a terminated facility within 90 days prior to the specialist/ facility contract termination date.” For data elements 16.42 – 16.51, please clarify how this would apply in a delegated model where one PCP may be in multiple medical groups the Plan is contracted with. For example, if a PCP were to be terminated in one medical group but active in other medical groups that the Plan is contracted with, would this be considered an “affected enrollee”?

CMS Response:

In this scenario, the PCP would not be considered a terminated PCP because he/she is still contracted with the organization and providing services to enrollees in the medical group that he/she remains active in.  Therefore, there would be no “affected enrollees.”

We will revise the section to read:

Affected enrollees are those enrollees who were assigned to a terminated PCP, or who were treated by a terminated specialist or received care in a terminated facility within 90 days prior to the specialist/facility contract termination date.

Payments to Providers

Commenter: 1jz-8lrx-yfor Central Health Plan of California

COMMENT:

1. How should the data be reported when the Plan pays a capitated payment to medical groups and the medical groups either pay downstream providers through fee-for-service or through capitation? Should all of the contracted providers under this group be reported under data element 17.4 or would we have to separate the providers that are paid a capitated rate into data element 17.5?
   
   

2. For data elements 17.6 – 17.10, would this include providers who have been terminated prior to the end of the reporting period?
   
   

3. For data elements 17.6 – 17.10, would this include contracted providers who have not received payments during the reporting period?
   
   

4. For data elements 17.6 – 17.10, would this include any of the following provider types: labs, hospitals, hospitalists, or skilled nursing facilities?

CMS Response:

1. See revised language. Capitated payments are reported in data element 17.10.

2. This includes all providers that have received payment during FY2016.

3. No, this would not include providers that have not received payments during the reporting period.

4. See revised language. No, this would not include labs, hospitals, hospitalists, or skilled nursing facilities.

Commenter: 1jz-8lrs-fzxw Gila Williams, Philadelphia, PA, 19103 or by email [email protected]

COMMENT:

1. Can you please clarify whether Medicare Advantage Organizations are providing the earned opportunity (target) or actual?

CMS Response: MAO organizations will be required to report information concerning actual payments to providers.

Commenter: 1jz-8lru-86vr Bobbi Utt, Danville, PA, 17822-3220 or by email [email protected]

COMMENT:

1. Should the changes indicated in this version of the Part C Reporting Package be applied to the Part C Reporting Sections that are due in February 2016 for 2015 dates of service?

CMS Response: No, this requirement will be effective in 2017 and will require reporting on 2016 data.

Commenter: 1jz-8lrv-t2zq Anonymous, TN 37228 or by email: [email protected]

COMMENT:

Will this apply to our delegates that process claims?

CMS Response: No, this does not apply to payments for administrative services. See revised language.

Commenter: 1jz-8lrv-xt26 Linda Serra, Albany, NY, 12205 or by email: [email protected]

COMMENT:

1. Please define 'link to quality' as stated in the Elements for this report.

2. Are CMS sponsored Medicare Advantage provider incentive programs, such as PQRS and PCIP, linked to quality?

3. We are assuming risk-based-only payment systems would not be considered to be linked to quality. Is this correct?

CMS Response:

1. Please see revised language.

2. Yes.

3. Risk based models would be reported under reporting category 17.10-population based payment.

Commentator: 1jz-8lrw-k7r9 Tracie Klingenberg, Portland, OR, 97232 or by email: [email protected]

COMMENT:

Kaiser Foundation Health Plan, Inc. and its subsidiary Health Plans ("Kaiser" or "Kaiser Permanente"), all of which are either Medicare Advantage organizations or Medicare Cost contractors pursuant to Section 1876 of the Social Security Act, appreciate the opportunity to comment upon the Draft CY 2016 Medicare Part C Reporting Requirements & Supporting Documents for Second Comment Opportunity to include a proposed new reporting section titled, "Payments to Providers." (See AHIP Medicare Update #15-86b, 9/22/15.) and related supporting documents as announced in the Federal Register notice (80 FR 51276, 8/24/15). Comments are set forth below.

The newly incorporated section titled "payment to providers" are very onerous requirements. Our organization does not catalogue provider contracts in this fashion. Tracking would all have to be done manually. It would also be a significant undertaking to evaluate each contract and include one of these elements and then have to identify costs associated with each provider. Additionally, while the definitions can be found on the CMS.gov web site, we recommend CMS clarify the definitions within the actual reporting requirements and define each payment type.

CMS Response: Thank you for your comment. We believe the reporting requirements are feasible and appropriate.

HRA Reporting

Commenter: 1jz-8lru-86vr Bobbi Jutt at [email protected]