II 

114TH CONGRESS 

1ST SESSION S. 2197 

To amend title XVIII of the Social Security Act to improve the risk 

adjustment under the Medicare Advantage program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

OCTOBER 22, 2015 

Mr. CRAPO (for himself, Mr. BENNET, and Mr. ISAKSON) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to improve 

the risk adjustment under the Medicare Advantage program, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Securing Care for Sen5 iors Act of 2015’’. 

6 SEC. 2. IMPROVEMENTS TO MA RISK ADJUSTMENT SYSTEM. 

7 Section 1853(a)(1)(C) of the Social Security Act (42 

8 U.S.C. 1395w–23(a)(1)(C)) is amended by adding at the 

9 end the following new clauses: 


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1 ‘‘(iv) EVALUATION AND SUBSEQUENT

2 REVISION OF THE RISK ADJUSTMENT SYS3 TEM TO ACCOUNT FOR CHRONIC CONDI4 TIONS AND OTHER FACTORS FOR THE

5 PURPOSE OF MAKING THE RISK ADJUST6 MENT SYSTEM MORE ACCURATE, TRANS7 PARENT, AND REGULARLY UPDATED.— 

8 ‘‘(I) REVISION BASED ON NUM9 BER OF CHRONIC CONDITIONS.—The 

10 Secretary shall revise for 2017 and 

11 periodically thereafter, the risk adjust12 ment system under this subparagraph 

13 so that a risk score under such sys14 tem, with respect to an individual, 

15 takes into account the number of 

16 chronic conditions with which the in17 dividual has been diagnosed. 

18 ‘‘(II) EVALUATION OF DIF19 FERENT RISK ADJUSTMENT MOD20 ELS.—The Secretary shall evaluate 

21 the impact of including two years of 

22 data to compare the models used to 

23 determine risk scores for 2013 and 

24 2014 under such system. 


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1 ‘‘(III) EVALUATION AND ANAL2 YSIS ON CHRONIC KIDNEY DISEASE

3 (CKD) CODES.—The Secretary shall 

4 evaluate the impact of removing the 

5 diagnosis codes related to chronic kid6 ney disease in the 2014 risk adjust7 ment model and conduct an analysis 

8 of best practices of MA plans to slow 

9 disease progression related to chronic 

10 kidney disease. 

11 ‘‘(IV) EVALUATION AND REC12 OMMENDATIONS ON USE OF ENCOUN13 TER DATA.—The Secretary shall 

14 evaluate the impact of including 10 

15 percent of encounter data in com16 puting payment for 2016 and the 

17 readiness of the Centers for Medicare 

18 & Medicaid Services to incorporate en19 counter data in risk scores. In con20 ducting such evaluation, the Secretary 

21 shall use data collected as encounter 

22 data on or after January 1, 2012, 

23 shall conduct statistical analyses on 

24 such data for accuracy and complete25 ness and issue recommendations for 


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1 improving such accuracy and com2 pleteness, and shall not increase the 

3 percentage of such encounter data 

4 used unless the Secretary releases the 

5 results of the analyses publicly, indi6 cates how such data will be weighted 

7 in computing the risk scores, and en8 sures that the data reflects the degree 

9 and cost of care coordination under 

10 MA plans. 

11 ‘‘(V) CONDUCT OF EVALUA12 TIONS.—Evaluations and analyses 

13 under subclauses (II) through (IV) 

14 shall include an actuarial opinion 

15 from the Chief Actuary of the Centers 

16 for Medicare & Medicaid Services 

17 about the reasonableness of the meth18 ods, assumptions, and conclusions of 

19 such evaluations and analyses. The 

20 Secretary shall consult with the Medi21 care Payment Advisory Commission 

22 and accept and consider comments of 

23 stakeholders, such as managed care 

24 organizations and beneficiary groups, 

25 on such evaluation and analyses. The 


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1 Secretary shall complete such evalua2 tions and analyses in a manner that 

3 permits the results to be applied for 

4 plan years beginning with the second 

5 plan year that begins after the date of 

6 the enactment of this clause. 

7 ‘‘(VI) IMPLEMENTATION OF RE8 VISIONS BASED ON EVALUATIONS.—If 

9 the Secretary determines, based on 

10 such an evaluation or analysis, that 

11 revisions to the risk adjustment sys12 tem to address the matters described 

13 in any of subclauses (II) through (IV) 

14 would make the risk adjustment sys15 tem under this subparagraph better 

16 reflect and appropriately weight for 

17 the population that is served by the 

18 plan, the Secretary shall, beginning 

19 with 2017, and periodically thereafter, 

20 make such revisions. 

21 ‘‘(VII) PERIODIC REPORTING TO

22 CONGRESS.—With respect to plan 

23 years beginning with 2017 and every 

24 third year thereafter, the Secretary 

25 shall submit to Congress a report on 


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1 the most recent revisions (if any) 

2 made under this clause, including the 

3 evaluations conducted under sub4 clauses (II) through (IV). 

5 ‘‘(v) NO CHANGES TO ADJUSTMENT

6 FACTORS THAT PREVENT ACTIVITIES CON7 SISTENT WITH NATIONAL HEALTH POLICY

8 GOALS.—In making any changes to the ad9 justment factors, including adjustment for 

10 health status under paragraph (3), the 

11 Secretary shall ensure that the changes do 

12 not prevent Medicare Advantage organiza13 tions from performing or undertaking ac14 tivities that are consistent with national 

15 health policy goals, including activities to 

16 promote early detection and better care co17 ordination, the use of health risk assess18 ments, care plans, and programs to slow 

19 the progression of chronic diseases. 

20 ‘‘(vi) OPPORTUNITY FOR REVIEW AND

21 PUBLIC COMMENT REGARDING CHANGES

22 TO ADJUSTMENT FACTORS.—For changes 

23 to adjustment factors effective for 2017 

24 and subsequent years, in addition to pro25 viding notice of such changes in the anVerDate Sep 11 2014 02:48 Oct 23, 2015 Jkt 059200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2197.IS S2197

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1 nouncement under subsection (b)(2), the 

2 Secretary shall provide an opportunity for 

3 review of proposed changes of not less than 

4 60 days and a public comment period of 

5 not less than 30 days before implementing 

6 such changes.’’. 

7 SEC. 3. SENSE OF CONGRESS RELATING TO MEDICARE AD8 VANTAGE RISK ADJUSTMENT. 

9 It is the sense of Congress that— 

10 (1) the Secretary of Health and Human Serv11 ices should periodically monitor and improve the 

12 Medicare Advantage risk adjustment model to en13 sure that it accurately accounts for beneficiary risk, 

14 including for those individuals with complex chronic 

15 comorbid conditions; 

16 (2) the Secretary should closely examine the 

17 current Medicare Advantage risk adjustment meth18 odology to ensure that plans enrolling beneficiaries 

19 with the greatest health care needs receive adequate 

20 reimbursement to deliver high-quality care and other 

21 services to help beneficiaries avoid costly complica22 tions and further progression of chronic conditions 

23 and to the extent data indicate this to be the case, 

24 the Secretary should make necessary adjustment to 

25 the risk adjustment methodology; and 


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1 (3) the Secretary should reconsider the imple2 mentation of changes in the Medicare Advantage 

3 risk adjustment methodology finalized for 2016 and 

4 to use to the extent appropriate the methodology fi5 nalized in 2015 for one additional year. 

Æ 


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