MA, D-SNP Sponsors Ask for Grace in Risk Score Determination

As CMS considers its final rate notice for the 2022 plan year and charts a full transition to the encounter data system (EDS) for calculating risk scores, Medicare Advantage insurers are pleading with the agency to grant them some leeway in the use of risk adjustment data to account for COVID-19 pandemic-related abnormalities. If plans are to rely on encounter data from 2020, a year when many enrollees put off care, their risk adjusted payments in 2021 may not be adequate — leading to even lower payments in 2022, two trade organizations warn.

In anticipation of an early rate notice release due to pandemic uncertainty, CMS on Oct. 30 issued Part 2 of the 2022 Advance Notice of Methodological Changes for MA Capitation Rates and Part D Payment Policies, which usually posts in early February (RMA 11/5/20, p. 1). The comment period for both parts of the notice closed on Nov. 30, and America’s Health Insurance Plans (AHIP), in its comment letter to CMS, said the notice failed to address policies needed to hold plans and enrollees harmless in relation to the pandemic. With lower care utilization resulting in fewer opportunities for providers to code diagnoses, risk scores gathered from 2020 may not accurately reflect the health of enrollees and therefore may not fully reflect the cost of care, warned AHIP.

© 2022 MMIT
Lauren Flynn Kelly

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues, including drug benefits and specialty pharmacy, for more than a decade. She served as editor of Drug Benefit News (the predecessor to Radar on Drug Benefits) from 2004 to 2005 and again from 2011 to 2016, and now manages Radar on Medicare Advantage. Lauren graduated from Vassar College with a B.A. in English.

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