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

Medicare Part C Reporting Requirements
Effective January 1, 2019

Prepared by:
Centers for Medicare & Medicaid Services
Center for Medicare
Medicare Drug Benefit and C&D Data Group

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time required to complete this information collection is estimated to average 15 hours per
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Table of Contents
INTRODUCTION AND GENERAL INFORMATION………………………………..1
REPORTING REQUIREMENT REPORTING SECTIONS LIST……………………2
I. GRIEVANCES…………………………………………………………………………………..4
II. ORGANIZATION DETERMINATIONS/RECONSIDERATIONS……………...6
III. EMPLOYER GROUP PLAN SPONSORS…………………………………….........9
IV. SPECIAL NEEDS PLANS (SNP) CARE MANAGEMENT………………………10
V. ENROLLMENT AND DISENROLLMENT…………………………………….........11
VI. REWARDS AND INCENTIVES PROGRAMS………………………………………13
VII. PAYMENTS TO PROVIDERS……………………………………………………………14

BACKGROUND AND INTRODUCTION
CMS has authority to establish reporting requirements for Medicare Advantage Organizations
(MAOs) as described in 42CFR §422.516 (a). Pursuant to that authority, each MAO must have
an effective procedure to develop, compile, evaluate, and report information to CMS in the time
and manner that CMS requires. Additional regulatory support for the Medicare Part C Reporting
Requirements is also found in the Final Rule entitled “Medicare Program; Revisions to the
Medicare Advantage and Prescription Drug Program” (CMS 4131-F).
Beginning with these CY 2019 two documenst will be provided to MAOs. The Reporting
Requirements thyat provide a description of each reporting section, reporting timeframes,
deadlines, and specific data elements for each reporting section. The second set of guidelines is
the Part C Technical Specifications that further define data elements and how CMS will review
and analyze the data. Technical Specifications do not change the data to be reported to CMS as
outlined in this document, but assist organizations in preparing and submitting accurate datasets
to CMS, thus reducing the need for organizations to correct and resubmit data.
All Part C Reporting Requirements documents will be posted at:
https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/ReportingRequirements.html
CMS believes providing these separate instructions will better serve the organizations reporting
these data, while satisfying the Paperwork Reduction Act requirements.
Organizations for which these specifications apply are required to collect these data. Reporting
will vary depending on the plan type and reporting section. Most reporting sections will be
reported annually.
The following data elements listed directly below are considered proprietary, and CMS considers
these as not subject to public disclosure under provisions of the Freedom of Information Act
(FOIA):*
• Employer DBA and Legal Name, Employer Address, Employer Tax Identification
Numbers (Employer Group Sponsors)...
*Under FOIA, Plans may need to independently provide justification for protecting these data if
a FOIA request is submitted.
In order to provide guidance to Part C Sponsors on the actual process of entering reporting
requirements data into the Health Plan Management System, a separate Health Plan Management
System (HPMS) Plan Reporting Module (PRM) User Guide may be found on the PRM start
page.
Exclusions from Reporting
National PACE Plans and 1833 Cost Plans are excluded from reporting all Part C Reporting
Requirements reporting sections.

The following summary table provides an overview of the
parameters around each of the current Part C Reporting
Requirements reporting sections.
Reporting
Section
I. Grievances

II. Organization
Determinations/
Reconsiderations

III. Employer
Group Plan
Sponsors

IV. Special
Needs Plans
(SNPs) Care
Management

Organization
Types Required
to Report
Coordinated
Care Plans
(CCPs), Provider
Fee-For-Service
Plans (PFFS),
1876 Cost,
Medicare
Savings
Accounts
(MSAs)
(includes all 800
series plans),
Employer/Union
Direct Contract
CCP, PFFS,
1876 Cost, MSA
(includes all 800
series plans),
Employer/Union
Direct Contract

Report
Report
Frequency
Period (s)
Level
1/Year
1/1-3/31
Contract
4/1-6/30
7/1-9/30
10/1-12/31
(reporting
will include
each quarter)

CCP, PFFS,
1876 Cost,
MSA (includes
800 series plans
and any
individual plans
sold to employer
groups),
Employer/Union
Direct Contract
Local CCP,
Regional CCP,
RFB Local CCP
with SNPs.
Includes 800
series plans.

1/year
PBP

1/Year
Contract

1/Year
PBP

Data Due date (s)

First Monday of
February
Validation
Required

1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31
(reporting
will include
each quarter)
1/1 - 12/31

Last Monday of
February in
following year

1/1-12/31

Last Monday of
February in the
following year.
Validation
required

Validation
required
First Monday of
February in the
following year.

Reporting
Section
V. Enrollment/
Disenrollment

VI. Rewards and
Incentives
Programs

VII. Payments to
Providers

Organization
Report
Report
Types Required Frequency
Period (s)
to Report
Level
Only 1876 Cost
2/Year
1/1-6/30
Plans with no
Contract
7/1-12/31
Part D.*
Local
Coordinated
Care Plans
(Local CCPs),
Medicare
Savings
Accounts
(MSAs),
Provider FeeFor-Service
Plans (PFFS),
and Regional
Coordinated
Care Plans
(Regional CCPs)
MMP’s
Local CCP
Regional CCP
RFB Local CCP
PFFS
MMP**

1/Year
Contract

1/1-12/31

1/Year
Contract

1/1-12/31

Data Due date (s)

Last Monday of
August and
February in the
following year.
Last Monday of
February in the
following year.

Last Monday of
February in the
following year.

* MA-only. MA-PDs and PDPs report under Part D. MSA and chronic care excluded.
** MMPs should report for all APMs, not just Medicare APMs.

REPORTING SECTIONS
I. Grievances
According to MMA statute, all Medicare Advantage organizations must provide meaningful
procedures for hearing and resolving grievances between enrollees, and the organization or any
other entity or individual through which the organization provides health care services under any
MA plan it offers. A grievance is any complaint or dispute, other than one that constitutes an
organization determination, expressing dissatisfaction with any aspect of an MA organization’s
or provider’s operations, activities, or behavior, regardless of whether remedial action is
requested. MA organizations are required to notify enrollees of their decision no later than 30
days after receiving their grievance based on the enrollee’s health condition. An extension up to
14 days is allowed if it is requested by the enrollee, or if the organization needs additional
information and documents that this extension is in the interest of the enrollee. An expedited
grievance that involves refusal by a MA organization to process an enrollee’s request for an
expedited organization determination or reconsideration requires a response from the MA
organization within 24 hours.
I. GRIEVANCES – this reporting section requires an upload.
Reporting
Organization
Report
Report
section
Types Required to
Frequency
Period (s)
Report
Level
01 – Local CCP
1/Year
1/1-3/31
Grievances
02 – MSA
/Contract level
4/1-6/30
03 – Religious
7/1-9/30
Fraternal
10/1-12/31
Benefit(RFB PFFS)
(reporting
04 – PFFS
will
06 – 1876 Cost
include
11 – Regional CCP
each
14 – Employee
quarter)
Union Direct (ED)PFFS
15 – RFB Local
CCP
Organizations
should include all
800 series plans.
Employer/Union
Direct Contracts
should also report
this reporting
section, regardless
of organization type.

Data Due date
(s)
First Monday of
February in the
following year.

Data
Element
ID
A.
B.
C.

Data Element Description

Number of Total Grievances
Number of Total Grievances in which timely notification was given
Number of Expedited Grievances

D.

Number of Expedited Grievances in which timely notification was given

E.

Number of Dismissed Grievances

II. ORGANIZATION DETERMINATIONS & RECONSIDERATIONS – this section
requires data entry and a file upload.
Organization Types
Required to Report
01 – Local CCP
02 –MSA
03 – RFB PFFS
04 –PFFS
06 – 1876 Cost
11 – Regional CCP
14 – ED-PFFS
15 – RFB Local CCP

Report
Frequency
Level
1/Year
Contract

Report
Period (s)

Data Due date (s)

1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31
(reporting
will
include
each
quarter)

Last Monday of February in the following
year.

Organizations should
include all 800 series
plans.
Employer/Union Direct
Contracts should also
report this reporting
section, regardless of
organization type.

Data Element
ID
Subsection # 1
A.
B.
C.
D.

Data Element Description
Organization Determinations
Total Number of Organization Determinations Made in the Reporting Period
Above
Number of Organization Determinations - Withdrawn
Number of Organization Determinations - Dismissals
Number of Organization Determinations requested by enrollee/representative or
provider on behalf of the enrollee (Services)

Data Element
ID
E.
F.
G.
Subsection #2:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Subsection #3:
A.
B.
C.
D.
E.
F.
G.
Subsection #4:
A.

Data Element Description
Number of Organization Determinations submitted by Enrollee/Representative
(Claims)
Number of Organization Determinations requested by Non-Contract Provider
(Services)
Number of Organization Determinations submitted by Non-Contract Provider
(Claims)
Disposition – All Organization Determinations
Number of Organization Determinations – Fully Favorable (Services)
Requested by enrollee/representative or provider on behalf of the enrollee
Number of Organization Determinations – Fully Favorable (Services)
Requested by Non-contract Provider
Number of Organization Determinations – Fully Favorable (Claims)
Submitted by enrollee/representative
Number of Organization Determinations – Fully Favorable (Claims)
Submitted by Non-contract Provider
Number of Organization Determinations – Partially Favorable (Services)
Requested by enrollee/representative or provider on behalf of the enrollee
Number of Organization Determinations – Partially Favorable (Services)
Requested by Non-contract Provider
Number of Organization Determinations – Partially Favorable (Claims)
Submitted by enrollee/representative
Number of Organization Determinations – Partially Favorable (Claims)
Submitted by Non-contract Provider
Number of Organization Determinations – Adverse (Services)
Requested by enrollee/representative or provider on behalf of the enrollee
Number of Organization Determinations – Adverse (Services)
Requested by Non-contract Provider
Number of Organization Determinations – Adverse (Claims)
Submitted by enrollee/representative
Number of Organization Determinations – Adverse (Claims)
Submitted by Non-contract Provider
Reconsiderations
Total number of Reconsiderations Made in Reporting Time Period Above
Number of Reconsiderations - Withdrawn
Number of Reconsiderations - Dismissals
Number of Reconsiderations requested by or on behalf of the enrollee (Services)
Number of Reconsiderations submitted by Enrollee/Representative (Claims)
Number of Reconsiderations requested by Non-Contract Provider (Services)
Number of Reconsiderations submitted by Non-Contract Provider (Claims)
Disposition – All Reconsiderations
Number of Reconsiderations – Fully Favorable (Services)
Requested by enrollee/representative or provider on behalf of the enrollee

Data Element
ID
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Subsection #5:
A.

B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.

Data Element Description
Number of Reconsiderations – Fully Favorable (Services)
Requested by Non-contract Provider
Number of Reconsiderations – Fully Favorable (Claims)
Submitted by enrollee/representative
Number of Reconsiderations – Fully Favorable (Claims)
Submitted byNon-contract Provider
Number of Reconsiderations – Partially Favorable (Services)
Requested by enrollee/representative or provider on behalf of the enrollee
Number of Reconsiderations – Partially Favorable (Services)
Requested by Non-contract Provider
Number of Reconsiderations – Partially Favorable (Claims)
Submitted by enrollee/representative
Number of Reconsiderations – Partially Favorable (Claims)
Submitted by Non-contract Provider
Number of Reconsiderations – Adverse (Services)
Requested by enrollee/representative or provider on behalf of the enrollee
Number of Reconsiderations – Adverse (Services)
Requested by Non-contract Provider
Number of Reconsiderations – Adverse (Claims)
submitted by enrollee/respresentative
Number of Reconsiderations – Adverse (Claims)
Submitted by Non-contract Provider
Re-openings
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:
Contract Number
Plan ID
Case ID
Case level (Organization Determination or Reconsideration)
Date of original disposition
Original disposition (Fully Favorable; Partially Favorable or Adverse)
Was the case processed under the expedited timeframe? (Y/N)
Case type (Service or Claim)
Status of treating provider (Contract, Non-contract)
Date case was reopened
Reason(s) for reopening (Clerical Error, Other Error, New and Material
Evidence, Fraud or Similar Fault, or Other)
Additional Information (Optional)
Date of reopening disposition (revised decision)*

Data Element
ID
O.

Data Element Description
Reopening disposition (Fully Favorable; Partially Favorable, Adverse or
Pending)

III. EMPLOYER GROUP PLAN SPONSORS - This reporting section requires an upload.
Organization Types
Required to Report
01 – Local CCP
02 – MSA
04 – PFFS
06 – 1876 Cost
11 – Regional CCP
14 – ED-PFFS

Report
Frequency/
Level
1/year PBP

Report
Period (s)
1/1 - 12/31

Data Due date (s)

First Monday of February in the
following year.

Organizations should
include all 800 series
plans and any
individual plans sold to
employer groups.

Employer/Union Direct
Contracts should also
report this reporting
section, regardless of
organization type.

Data
Element ID
A.
B.
C.
D
E.
F.
G.
H.
I.
J.

Data Element Description
Employer Legal Name
Employer DBA Name
Employer Federal Tax ID
Employer Address
Type of Group Sponsor (employer, union, trustees of a fund)
Organization Type (State Government, Local Government, Publicly Traded
Organization, Privately Held Corporation, Non-Profit, Church Group, Other)
Type of Contract (insured, ASO, other)
Is this a calendar year plan? (Y (yes) or N (no))
If data element His a “N", provide non-calendar year start date.
Current/Anticipated Enrollment

IV. SPECIAL NEEDS PLANS (SNPs) CARE MANAGEMENT - This reporting section
requires direct data entry into HPMS.
Organization Types
Required to Report
SNP PBPs under the
following types:
01 – Local CCP
11 – Regional CCP
15 – RFB Local CCP

Report
Frequency
Level
1/Year
PBP

Report
Period (s)
1/1-12/31

Data Due date (s)

Last Monday of February in the
following year.

Organizations should
exclude 800 series
plans if they are SNPs.

Data Element ID

Data Element Description

A.

Number of new enrollees due for an Initial Health Risk Assessment
(HRA)

B.
C.

Number of enrollees eligible for an annual reassessment HRA
Number of initial HRAs performed on new enrollees

D.
E.

Number of initial HRA refusals
Number of initial HRAs not performed because SNP is unable to
reach new enrollees
Number of annual reassessments performed on enrollees eligible for a
reassessment
Number of annual reassessment refusals
Number of annual reassessments where SNP is unable to reach
enrollee

F.
G.
H.

Notes:
If a new enrollee does not receive an initial HRA within 90 days of enrollment that enrollee’s
annual HRA is due to be completed within 365 days of enrollment. A new enrollee who receives
an HRA within 90 days of enrollment is due to complete a reassessment HRA no more than 365
days after the initial HRA was completed.

V. ENROLLMENT AND DISENROLLMENT - This reporting section requires data entry.
Organization Types Report Frequency
Report
Data Due date (s)
Required to Report*
Level
Period (s)
MAOs offering MA- 2/Year
1/1 - 6/30
Last Monday of August and
only (no Part D) plans Contract
7/1 – 12/31 February
1876 Cost Plans
(enrollments that do
not include a Part D
optional supplemental
benefit)
CMS provides guidance for MAOs and Part D sponsors’ processing of enrollment and
disenrollment requests.
CMS will collect data on the elements for these requirements, which are otherwise not available
to CMS, in order to evaluate the sponsor’s processing of enrollment, disenrollment and
reinstatement requests in accordance with CMS requirements. For example, while there are a
number of factors that result in an individual’s eligibility for a Special Enrollment Period (SEP),
sponsors are currently unable to specify each of these factors when submitting enrollment
transactions. Sponsor’s reporting of data regarding SEP reasons for which a code is not currently
available will further assist CMS in ensuring sponsors are providing support to beneficiaries,
while complying with CMS policies.
Note: Both Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Medicare
Prescription Drug Manual outline the enrollment and disenrollment periods (Section 30).

Data Element
ID
Subsection #1
A

B.

C.

D.

E.
F.

G.
H.
I.

J.

Data Element Description
Enrollment
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.
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).
Of the total reported in A, the number of enrollment requests for which the sponsor
was required to request additional information from the applicant (or his/her
representative).
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 (i.e. individual
not eligible for an election period).
Of the total reported in C, the number of incomplete enrollment requests received that
are incomplete upon initial receipt and completed within established timeframes.
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.
Of the total reported in A, the number of paper enrollment requests received
Of the total reported in A, the number of telephonic enrollment requests received (if
sponsor offers this mechanism).
Of the total reported in A, the number of electronic enrollment requests received via an
electronic device or secure internet website (if sponsor offers this mechanism).

Of the total reported in A, the number of Medicare Online Enrollment Center (OEC)
enrollment requests received.
K.
Of the total 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.
Subsection #2: Disenrollment
A.
The total number of voluntary disenrollment requests received in the specified time
period. Do not include disenrollments resulting from an individual’s enrollment in
another plan.
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 F, the number of individuals reinstated

VI. REWARDS AND INCENTIVES PROGRAMS: is a partial data entry and upload.
Organization Types
Required to Report
01 – Local CCP
02 – MSA
03 – RFB PFFS
04 – PFFS
05 – MMP
11 – Regional CCP
14 – ED-PFFS
15 – RFB Local CCP

Report
Report
Frequency Period (s)
Level
1/Year
1/1-12/31
Contract

Data Due date (s)

Last Monday of February in following
year

Organizations should include
all 800 series plans.
Employer/Union Direct
Contracts should also report
this reporting section,
regardless of organization
type.
A plan user needs to select "Yes" or "No" for data element A. on the edit page. If the plan user
selected "No", no upload is necessary. If the plan user selects "Yes", then the user will be
required to upload additional information in accordance with the file record layout.
Data
Element ID
A.
B.
C.
D.
E.
F.
G.

Data Element Description
Do you have a Rewards and Incentives Program(s)? (“Yes“ or “No”
only; )
What health related services and/or activities are included in the
program? [Text ]
What reward(s) may enrollees earn for participation? [Text ]
How do you calculate the value of the reward? [Text ]
How do you track enrollee participation in the program? [Text ]
How many enrollees are currently enrolled in the program? Enter
______
How many rewards have been awarded so far? Enter_______

VII. PAYMENTS TO PROVIDERS - This reporting section requires a file upload.
Collecting these data will help to inform us as we determine how broadly MA organizations are
using alternative payment arrangements.
Organization Types
Required to Report

Report
Report
Frequency Period (s)
Level
1/Year
1/1-12/31
Contract

Data Due date (s)

01 – Local CCP
Last Monday of February in the following
11 – Regional CCP
year.
15 – RFB Local CCP
04 – PFFS
05 – MMP*
*MMPs should report for all APMs not just Medicare APMs.
Data
Data Element Description
Element ID
A.
Total Medicare Advantage payment made to contracted providers.
B.
Total Medicare Advantage payment made on a fee-for-service basis with no
link to quality (category 1).
C.
Total Medicare Advantage payment made on a fee-for-service basis with a
link to quality (category 2).
D.
Total Medicare Advantage payment made using alternative payment models
built on fee-for-service architecture (category 3)
E.
Total Risk-based payments not linked to quality (e.g. 3N in APM definitional
framework)
F.
Total Medicare Advantage payment made using population-based payment
(category 4).
G.
Total capitation payment not linked to quality (e.g. 4N in the APM
definitional framework)
H.
Total number of Medicare Advantage contracted providers.
I.
Total Medicare Advantage contracted providers paid on a fee-for-service basis
with no link to quality (category 1).
J.
Total Medicare Advantage contracted providers paid on a fee-for-service basis
with a link to quality (category 2).
K.
Total Medicare Advantage contracted providers paid based on alternative
payment models built on a fee-for-service architecture (category 3).
L.
Total Medicare Advantage contracted providers paid based risk-based
payments not linked to quality (e.g. 3N in the APM definitional framework)
M.
Total Medicare Advantage contracted providers paid based on population
based payment (category 4).
N.
Total Medicare Advantage contracted providers paid based on capitation with
no link to quality (e.g. category 4N in the APM definitional framework).