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

Draft Medicare Part C Reporting Requirements
Effective January 1, 2021

Prepared by:
Centers for Medicare & Medicaid Services
Center for Medicare
Medicare Drug Benefit and C&D Data Group
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1054 (expires on). The time required to complete this information
collection is estimated to average 42 hours per response, including the time to review instructions, search
existing data resources, and gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C426-05, and Baltimore, Maryland 21244-1850.

Table of Contents
I.

GRIEVANCES ....................................................................................................................... 5

II.

ORGANIZATION DETERMINATIONS & RECONSIDERATIONS ............................ 7

III.

EMPLOYER GROUP PLAN SPONSORS ....................................................................... 10

IV.

SPECIAL NEEDS PLANS (SNPs) CARE MANAGEMENT .......................................... 11

V.

ENROLLMENT AND DISENROLLMENT ..................................................................... 12

VI.

REWARDS AND INCENTIVES PROGRAMS ................................................................ 14

VII.

PAYMENTS TO PROVIDERS .......................................................................................... 15

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).
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.

Page 1 of 19

Overview of the parameters for current Part C Reporting Requirements reporting sections.
Data Due date (s)
Reporting
Organization
Report
Report
Section
Types Required
Frequency
Period (s)
to Report
Level
1/1-3/31
I. Grievances
Coordinated Care
1/Year
First Monday of
4/1-6/30
Plans (CCPs),
Contract
February
7/1-9/30
Provider Fee-For10/1-12/31
Service Plans
Validation
(reporting
(PFFS), 1876
Required
will
Cost, Medicare
include
Savings Accounts
each
(MSAs)
quarter)
(includes all 800
series plans),
Employer/Union
Direct Contracts
II. Organization
Determinations/
Reconsiderations

III. Employer
Group Plan
Sponsors

Page 2 of 19

CCP, PFFS,
1876 Cost,
MSA,RFB,
PFFS
(Includes all 800
series plans),
Employer/Union
Direct Contracts
should also report
this section
regardless of
organization
type.

1/Year
Contract

CCP, PFFS,1876
Cost, MSA
(includes 800
series plans and
any individual
plans sold to
employer groups),
Employer/Union
Direct Contracts
should also report
this section,
regardless of
Organization type

1/year
PBP

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
following year

1/1 - 12/31

First Monday of
February in the
following year.

Validation
required

Reporting
Section
IV. Special
Needs Plans
(SNPs) Care
Management

V. Enrollment/
Disenrollment

VI. Rewards and
Incentives
Programs

VII. Payments to
Providers

1

Organization
Types Required
to Report
Local CCP,
Regional CCP,
RFB Local CCP
with SNPs.
Includes 800
series plans if
they are
SNPs.
MAOs offering
MA only (no
Part D) plans
1876 Cost Plans
with no Part D. 1
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

MA only. MAPD and PDPs report under Part D.

Page 3 of 19

Report
Frequency
Level
1/Year
PBP

Report
Period (s)

Data Due date (s)

1/1-12/31

Last Monday of
February in the
following year.
Validation
required

1/1-6/30
7/1-12/31

Last Monday of
August and
February in the
following year.

1/Year
Contract

1/1-12/31

Last Monday of
February in the
following year.

1/Year
Contract

1/1-12/31

Last Monday of
February in the
following year.

2/Year
Contract

Reporting
Section
VIII.
Additional
Telehealth
Benefits

Organization
Types Required
to Report
Local CCP
MSA and
PFFS 2
Regional
CCP

Report
Frequency
Level
1/Year
Contract

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

Data Due date (s)

Last Monday
of February
in the
following
year.

RFB
Local
CCP 3

2

Only network based MSA and PFFS plans are required to report.
Regional Preferred Provider Organizations (RPPOs) should only report on the network areas of their plans (not the
non-network areas).

3

Page 4 of 19

REPORTING SECTIONS
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
section

Organization Types
Required to Report

Grievances

01 – Local CCP
02 – MSA
03 – Religious
Fraternal Benefit
(RFB PFFS)
04 – PFFS
06 – 1876 Cost
11 – Regional CCP
14 – Employee
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.

Page 5 of 19

Report
Frequency
Level
1/Year
/Contract level

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)

First Monday
of February
in the
following
year.

Data Element ID
A.
B.
C.
D.
E.

Page 6 of 19

Data Element Description
Number of Total Grievances
Number of Total Grievances in which timely notification was given
Number of Expedited Grievances
Number of Expedited Grievances in which timely notification was given
Number of Dismissed Grievances

II.

ORGANIZATION DETERMINATIONS & RECONSIDERATIONS

This section requires 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.

Data Element Description

B.

Organization Determinations
Total Number of Organization Determinations Made in the Reporting Period
Above
Number of Organization Determinations - Withdrawn

C.

Number of Organization Determinations - Dismissals

D.

Number of Organization Determinations requested by enrollee/representative or
provider on behalf of the enrollee (Services)
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

E.
F.
G.
Subsection #2
A.

Page 7 of 19

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

Page 8 of 19

Data Element Description
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
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 by Non-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

Data Element ID
G.
H.
I.
J.
K.
L.
Subsection #5:
A.

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

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

The date of disposition is the date the required written notice of a revised decision was sent per 405.982*

Page 9 of 19

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.

Page 10 of 19

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
A.

Data Element Description

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.

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

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.

Page 11 of 19

V.

ENROLLMENT AND DISENROLLMENT
This reporting section requires direct data entry into HPMS.
Organization Types
Required to Report*
MAOs offering MA- only
(no Part D) plans

Report Frequency
Level
2/Year
Contract

Report
Period
1/1 - 6/30
7/1 –
12/31

Data Due date (s)
Last Monday
of August and
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).
For questions specific to enrollment/disenrollment requirements please contact the following
mailbox: https://enrollment.lmi.org
Data
Element ID
Subsection #1
A

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.

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 for which
the sponsor was required to request additional information from the
applicant (or his/her representative).

Page 12 of 19

Data
Element ID
D.

E.

F.

G.

Data Element
Description
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

H.

Of the total reported in A, the number of telephonic enrollment requests
received (if sponsor offers this mechanism).

I.

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).

J.

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:
A.

Disenrollment
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.
G.

Of the total reported in E, the number of favorable Good Cause.
Of the total reported in G, the number of individuals reinstated.

Page 13 of 19

VI.
REWARDS AND INCENTIVES PROGRAMS
This is a partial data entry into HPMS and upload.
Organization Types Required to
Report
01- Local CCP
02- MSA
03- RFB PFFS
04- PFFS
05- MMP
11- Regional CCP
12- 14- ED-PFFS
13- 15 - RFB Local CCP

Report
Frequency
Level
1/Year
Contract

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

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.

Data Element Description
Do you have a Rewards and Incentives Program(s)? (“Yes“ or “No”
only; )
Rewards and Incentives Program Name

D.

What health related services and/or activities are included in the
program? [Text ]
What reward(s) may enrollees earn for participation? [Text ]

E.
F.
G.

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? [NUM]

H.

How many rewards have been awarded so far? [NUM]

Page 14 of 19

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. See Technical Specs for additional information.
Data Due date (s)
Organization Types
Report
Report
Required to Report
Frequency Level Period (s)
01 – Local CCP
04 - PFFS
05 – MMP*
11 – Regional CCP
15 – RFB Local CCP

1/Year Contract

1/1-12/31

Last Monday of February
in the following year.

*MMPs should report for all APMs not just Medicare APMs.
Data
Element
ID
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
Page 15 of 19

Data Element Description

Total Medicare Advantage payment made to contracted providers.
Total Medicare Advantage payment made on a fee-for-service basis with no
link to quality (category 1).
Total Medicare Advantage payment made on a fee-for-service basis with a
link to quality (category 2).
Total Medicare Advantage payment made using alternative payment models
built on fee-for-service architecture (category 3)
Total Risk-based payments not linked to quality (e.g. 3N in APM definitional
framework)
Total Medicare Advantage payment made using population-based payment
(category 4).
Total capitation payment not linked to quality (e.g. 4N in the APM
definitional framework)
Total number of Medicare Advantage contracted providers.
Total Medicare Advantage contracted providers paid on a fee-for-service basis
with no link to quality (category 1).
Total Medicare Advantage contracted providers paid on a fee-for-service basis
with a link to quality (category 2).
Total Medicare Advantage contracted providers paid based on alternative
payment models built on a fee-for-service architecture (category 3).
Total Medicare Advantage contracted providers paid based risk-based
payments not linked to quality (e.g. 3N in the APM definitional framework)
Total Medicare Advantage contracted providers paid based on population
based payment (category 4).
Total Medicare Advantage contracted providers paid based on capitation with
no link to quality (e.g. category 4N in the APM definitional framework).

Page 16 of 19

Page 17 of 19