CMS uses the risk adjustment data to
develop individual risk scores for risk adjusted payment under Part
C. As required by law, CMS also establishes the risk adjustment
methodology and annually publishes the risk adjustment factors for
MA organizations and other interested entities in the Advance
Notice of Methodological Changes for MA Payment Rates (every
February) and the Announcement of Medicare Advantage Payment Rates
(every April). Risk adjustment data in particular is used to
calibrate the CMS-HCC risk adjustment models using MA patterns of
diagnoses, utilization, and expenditures. While establishing a risk
adjustment model appropriate for the MA program is the paramount
reason for collecting MA risk adjustment, there are other important
uses of the data that will improve other key functions undertaken
by CMS. Data is used for the calculation of Medicare
Disproportionate Share Hospital (DSH) payments. CMS collects
inpatient stay information for the Medicare managed care enrollees.
In particular, we collect the admission date, discharge date,
Health Insurance Claim Number (HICN), and Medicare hospital
number/CCN. Further, we also use the data for quality review and
improvement activities. For example, MA risk adjustment data may be
used in the development and calculation of quality measures for MA
organizations. Other uses for the data include geographical acuity
studies, utilization trends and detection of abuse as defined in
the False Claim Act. Additional uses for the data include verifying
the accuracy and validity of the reasonable costs claimed on Cost
Reports submitted by section 1876 Cost HMOs/CMPs and section 1833
HCPPs. Finally, as stated in the regulation, we use the data for
Medicare coverage purposes. For example, we can use risk adjustment
data for the determination of whether day limits have been
exhausted and, if not, how many such days are left.
US Code:
42
USC 1395w-23 Name of Law: Risk Adjusted Part D Payment
US Code: 42
USC 1395w-23 Name of Law: Risk Adjusted Part C Payment
US Code: 42
USC 1395w-23 Name of Law: Data Collection
The currently approved title
for this information collection request is, “Collection of
Encounter Data from Medicare Advantage Organizations.” This
iteration proposes to revise the title to read, “Collection of Risk
Adjustment Data from MA Organizations, Section 1876 Cost HMOS/CMPS,
Section 1833 HCPPS, MMPS), and PACE Organizations.” We have revised
the CSSC Operations Submitter Application Instruction and CSSC
Operations Submitter Authorization Forms (see the attached
Crosswalk). Our currently approved burden estimates have not been
revised as a result of these changes. While the number of
respondents has been adjusted by +8 (from 683 (currently approved)
to 691 (proposed), our total time estimate has decreased by -28,136
hours (664 hr -28,800 hr). This net reduction includes -28,800
hours under the Risk Adjustment Data Submission ICR along with +664
hours for the remaining ICRs. Institutional, Professional, and DME
companion guides have been added to this package since the system
processes all institutional, professional, and DME claims. The
burden for these claims is built into the cost of effort for a plan
per year that is calculated in section 12 of this Supporting
Statement, listed as $840,810. DME claims for risk adjustment data
is a smaller portion of Part B claims and therefore the process to
create the data in the same format is reduced. We are also
requiring that accountable MA management approve their contract
jurisdiction before any pharmacy reconciliation reports are
submitted to them by completing a PRS Contract and Contact
Verification Form. We have clarified the submission timeframes in
section 6 of this Supporting Statement based on the release of the
reconciliation reports. This information collection effort includes
a data collection instrument that is updated annually to validate
accountable MA management (i.e. Survey or form).
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form CMS-10340 Submitter Authorization Form
CMS-10340 - Supporting Statement A rev 01-03-2017 - Passback2_04052018 [rev 04-13-2018 by OSORA PRA].docx
Crosswalk - Submitter Application 12_2_2 and Submitter Authorization 12_2_3 (rev OSORA PRA).xlsx
SSN Justification.pdf
PRS Contract and Contact Verification Form