I 

118TH CONGRESS 

1ST SESSION H. R. 5854 

To amend title XVIII of the Social Security Act to require complete and 

accurate data set submissions from Medicare Advantage organizations 

offering Medicare Advantage plans under part C of the Medicare program 

to improve transparency, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

SEPTEMBER 29, 2023 

Ms. PORTER (for herself, Ms. DEGETTE, Mr. DOGGETT, and Ms. SCHAKOWSKY) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to require 

complete and accurate data set submissions from Medicare Advantage organizations offering Medicare Advantage plans under part C of the Medicare program to 

improve transparency, 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 ‘‘Medicare Advantage 

5 Consumer Protection and Transparency Act’’. 


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1 SEC. 2. MEDICARE ADVANTAGE SUPPLEMENTAL BENEFITS 

2 DATA. 

3 (a) IN GENERAL.—Section 1852(c) of the Social Se4 curity Act (42 U.S.C. 1395w–122(c)) is amended by add5 ing at the end the following new paragraph: 

6 ‘‘(3) SUPPLEMENTAL BENEFITS DATA.— 

7 ‘‘(A) SUBMISSIONS TO SECRETARY.—For 

8 each plan year beginning on or after January 1 

9 of the second year beginning on or after the 

10 date of enactment of this paragraph, a Medi11 care Advantage organization offering supple12 mental benefits described in subsection (a)(3) 

13 under a Medicare Advantage plan shall submit 

14 (or, in the case of such an organization that 

15 contracts with an entity (such as a third-party 

16 contractor) to provide supplemental benefits in 

17 connection with such plan, require under such 

18 contract for the entity to submit), not later 

19 than 6 months after the end of the plan year, 

20 to the Secretary, in a clear, accurate, and 

21 standardized form in accordance with subpara22 graph (B) complete and accurate (as specified 

23 by the Secretary pursuant to subparagraph 

24 (B)) information, at the plan level and pre25 sented by coverage, service, or benefit type (as 

26 applicable), on such benefits offered under such 


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1 plan during the plan year, including regarding 

2 the following: 

3 ‘‘(i) The type and nature of each sup4 plemental benefit so offered during such 

5 plan year. 

6 ‘‘(ii) The number of Medicare Advan7 tage eligible individuals enrolled under plan 

8 during such plan year with coverage that 

9 enables access to such benefits. 

10 ‘‘(iii) The number of Medicare Advan11 tage eligible individuals enrolled under the 

12 plan during such plan year who received a 

13 service with respect to each such supple14 mental benefit type so offered. 

15 ‘‘(iv) The total plan and beneficiary 

16 expenditures made for such supplemental 

17 benefits, with respect to such plan year, 

18 excluding profits, administrative costs, and 

19 other overhead expenses. 

20 ‘‘(v) The total beneficiary cost sharing 

21 for supplemental benefits, with respect to 

22 such plan year, reported in total bene23 ficiary expenditure and as a percentage of 

24 total expenditure. 


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1 ‘‘(vi) All encounter data related to 

2 claims for supplemental benefits so offered, 

3 with respect to such plan year. 

4 ‘‘(vii) All payment data, disaggregated 

5 by contributing payer, related to claims for 

6 supplemental benefits so offered, with re7 spect to such plan year. 

8 ‘‘(viii) Such other information as spec9 ified by the Secretary. 

10 ‘‘(B) REGULATIONS.—Not later than July 

11 1 of the first year beginning on or after the 

12 date of the enactment of this paragraph, for 

13 purposes of subparagraph (A), the Secretary 

14 shall, through rulemaking— 

15 ‘‘(i) establish procedures to stand16 ardize the language used in describing sup17 plemental benefits (including categories of 

18 such benefits) and metrics; 

19 ‘‘(ii) establish procedures to stand20 ardize the collection and evaluation of data 

21 under such subparagraph; 

22 ‘‘(iii) analyze and publicly report, in 

23 common language, the standardized lan24 guage to be used by plans in describing 

25 supplemental benefits (including categories 


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1 of such benefits) in any materials intended 

2 for potential consumers, including mar3 keting materials, plan comparison tools 

4 under section 1851(d), and any other ma5 terials the Secretary deems appropriate; 

6 ‘‘(iv) specify metrics and methods for 

7 determining whether information sub8 mitted under subparagraph (A) is complete 

9 and accurate, including by requiring such 

10 information include at least comparisons of 

11 supplemental benefit information between 

12 encounter records submitted under 

13 1852(c)(3)(A)(vi), aggregate data sub14 mitted under 1852(c)(3)(A)(i–v), spending 

15 data for types and categories of supple16 mental benefits submitted under 

17 1857(e)(4), and supplemental benefit infor18 mation submitted under 1854(a)(6)(A); 

19 and 

20 ‘‘(v) determine categories or levels of 

21 incompleteness for plans that do not sub22 mit complete encounter data. 

23 In carrying out clause (iv), a Medicare Advan24 tage plan shall be treated as not submitting 

25 complete encounter data if the Secretary deterVerDate Sep 11 2014 03:59 Oct 11, 2023 Jkt 049200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H5854.IH H5854

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1 mines the plan has submitted less than 90 per2 cent of encounter data, including with respect 

3 to the data sources identified in clause (ii).’’. 

4 (b) PENALTY FOR NOT SUBMITTING INFORMA5 TION.—Section 1853(a)(1) of the Social Security Act (42 

6 U.S.C. 1395w–23(a)(1)) is amended— 

7 (1) in subparagraph (B)— 

8 (A) in clause (i), by striking ‘‘subpara9 graphs (F) and (G)’’ and inserting ‘‘subpara10 graphs (F), (G), and (J)’’; 

11 (B) in clause (ii), by striking ‘‘subpara12 graphs (F) and (G)’’ and inserting ‘‘subpara13 graphs (F), (G), and (J)’’; and 

14 (C) in clause (iii), by inserting ‘‘and (if ap15 plicable) under subparagraph (J)’’ after ‘‘sub16 paragraph (C)’’; and 

17 (2) by adding at the end the following new sub18 paragraph: 

19 ‘‘(J) ADJUSTMENT FOR NOT SUBMITTING

20 SUPPLEMENTAL BENEFIT INFORMATION.—In 

21 the case of a Medicare Advantage plan offered 

22 by a Medicare Advantage organization that, 

23 with respect to a plan year (beginning on or 

24 after January 1 of the second year beginning 

25 on or after the date of the enactment of this 


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1 subparagraph), has not submitted complete and 

2 accurate information, as required under section 

3 1852(c)(3), for each month during such plan 

4 year (until such month, if any, during such plan 

5 year during which the organization submits 

6 such complete and accurate information (as de7 termined in accordance with the metrics and 

8 methods specified pursuant to section 

9 1852(c)(3)(B))), the monthly payment amount 

10 specified in clauses (i), (ii), and (iii) of subpara11 graph (B), as applicable, shall be reduced by 5 

12 percent of the amount that would otherwise 

13 apply.’’. 

14 SEC. 3. MEDICARE ADVANTAGE ENCOUNTER DATA AC15 COUNTABILITY. 

16 (a) IN GENERAL.—Section 1852(c) of the Social Se17 curity Act (42 U.S.C. 1395w–122(c)), as amended by sec18 tion 2, is further amended by adding at the end the fol19 lowing new paragraph: 

20 ‘‘(4) ENCOUNTER DATA ACCOUNTABILITY.— 

21 ‘‘(A) SUBMISSIONS TO SECRETARY.—For 

22 each plan year beginning on or after January 1 

23 of the second year beginning on or after the 

24 date of the enactment of this paragraph, a 

25 Medicare Advantage organization offering a 


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1 Medicare Advantage plan shall, in accordance 

2 with the regulations promulgated pursuant to 

3 subparagraph (B), submit to the Secretary, not 

4 later than 6 months after the end of the plan 

5 year, complete and accurate (as specified by the 

6 Secretary pursuant to such regulations) pay7 ment data, disaggregated by plan and bene8 ficiary expenditure, and encounter data for all 

9 encounters covered through benefits under the 

10 original fee-for-service program defined under 

11 subsection (a)(1)(B) occurring during the plan 

12 year with respect to Medicare Advantage eligi13 ble individuals enrolled under such plan during 

14 such plan year. 

15 ‘‘(B) REGULATIONS.—Not later than July 

16 1 of the first year beginning on or after the 

17 date of the enactment of this paragraph, for 

18 purposes of subparagraph (A), the Secretary 

19 shall, through rulemaking— 

20 ‘‘(i) specify metrics and methods for 

21 determining whether information sub22 mitted under subparagraph (A) is complete 

23 and accurate, which shall include, as appli24 cable, at least comparisons between— 


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1 ‘‘(I) encounter records submitted 

2 under this section; 

3 ‘‘(II) patient assessment forms 

4 for home health (using information 

5 submitted through the Outcome and 

6 Assessment Information Set instru7 ment or a successor instrument), 

8 skilled nursing (using information 

9 submitted through the Minimum Data 

10 Set tool (or a successor tool)), and in11 patient rehabilitation services (using 

12 information submitted through the In13 patient Rehabilitation Facility Patient 

14 Assessment Instrument (or a suc15 cessor instrument)); 

16 ‘‘(III) monthly dialysis indicators 

17 used for risk adjustment; 

18 ‘‘(IV) Medicare Provider and 

19 Analysis Review data; 

20 ‘‘(V) service utilization data sub21 mitted under section 1854(a)(6)(A); 

22 and 

23 ‘‘(VI) any other data source or 

24 method as specified by the Secretary; 

25 and 


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1 ‘‘(ii) determine categories or levels of 

2 incompleteness for Medicare Advantage 

3 plans that do not submit complete encoun4 ter data. 

5 In carrying out clause (ii), a Medicare Advan6 tage plan shall be treated as not submitting 

7 complete encounter data if the Secretary deter8 mines the plan has submitted less than 90 per9 cent of encounter data, including with respect 

10 to the data sources identified in clause (i). 

11 ‘‘(C) PUBLIC REPORTING.—Beginning not 

12 later than July 1 of the second year beginning 

13 on or after the date of the enactment of this 

14 paragraph, the Secretary shall publicly report 

15 the data submitted pursuant to subparagraph 

16 (A).’’. 

17 (b) PENALTY FOR NOT SUBMITTING INFORMA18 TION.—Section 1853(a)(1) of the Social Security Act (42 

19 U.S.C. 1395w–23(a)(1)), as amended by section 2, is fur20 ther amended— 

21 (1) in subparagraph (B)— 

22 (A) in clause (i), by striking ‘‘(G), and 

23 (J)’’ and inserting ‘‘(G), (J), and (K)’’; 

24 (B) in clause (ii), by striking ‘‘(G), and 

25 (J)’’ and inserting ‘‘(G), (J), and (K)’’; and 


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1 (C) in clause (iii), by striking ‘‘subpara2 graph (J)’’ and inserting ‘‘subparagraphs (J) 

3 and (K)’’; and 

4 (2) by adding at the end the following new sub5 paragraph: 

6 ‘‘(J) ADJUSTMENT FOR NOT SUBMITTING

7 ENCOUNTER DATA.— 

8 ‘‘(i) IN GENERAL.—In the case of a 

9 Medicare Advantage plan offered by a 

10 Medicare Advantage organization that, 

11 with respect to a plan year (beginning on 

12 or after January 1 of the second year be13 ginning on or after the date of the enact14 ment of this subparagraph), has not sub15 mitted any encounter information under 

16 section 1852(c)(4), for each month during 

17 such plan year (until such month, if any, 

18 during such plan year during which the or19 ganization submits such information), the 

20 monthly payment amount specified in 

21 clauses (i) and (ii) of subparagraph (B) 

22 shall be reduced by 10 percent of the 

23 amount that would otherwise apply. 

24 ‘‘(ii) REDUCTION FOR INCOMPLETE

25 DATA SUBMITTED.—In the case of a MediVerDate Sep 11 2014 00:05 Oct 05, 2023 Jkt 049200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H5854.IH H5854

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1 care Advantage plan offered by a Medicare 

2 Advantage organization that, with respect 

3 to a plan year (beginning on or after Janu4 ary 1 of the second year beginning on or 

5 after the date of the enactment of this sub6 paragraph), has submitted encounter infor7 mation, as required under section 

8 1852(c)(4), but such information is not 

9 complete or is not accurate, as required 

10 under such section, for each month during 

11 such plan year (until such month, if any, 

12 during such plan year during which the or13 ganization submits such complete and ac14 curate information), the monthly payment 

15 amount specified in clauses (i), (ii), and 

16 (iii) of subparagraph (B), as applicable, 

17 shall be reduced by a percent specified by 

18 the Secretary (not to exceed 5 percent) of 

19 the amount that would otherwise apply. 

20 Such percent specified by the Secretary 

21 shall be based on the percentage of infor22 mation missing in the submission and de23 termined pursuant to rulemaking. 


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1 ‘‘(iii) PROCESS.—In applying the re2 ductions under this subparagraph, the Sec3 retary— 

4 ‘‘(I) shall provide public justifica5 tion for any percent reduction applied 

6 pursuant to clause (ii), including data 

7 used to arrive at the determination of 

8 the percent so applied; 

9 ‘‘(II) may authorize an internal 

10 entity or contract with an external en11 tity to assist with carrying out sub12 clause (I) and determining any per13 cent reduction to be applied under 

14 clause (ii); and 

15 ‘‘(III) shall establish a mecha16 nism for Medicare Advantage organi17 zations to appeal determinations 

18 under this subparagraph, with respect 

19 to such organization. 

20 ‘‘(iv) COLLECTION OF DATA THROUGH

21 MEDICARE ADMINISTRATIVE CONTRAC22 TORS.—The Secretary shall implement a 

23 mechanism requiring direct submission of 

24 provider claims to Medicare Administrative 

25 Contractors— 


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1 ‘‘(I) for Medicare Advantage 

2 plans that submit incomplete or inac3 curate encounter information under 

4 this subparagraph for 2 consecutive 

5 years; and 

6 ‘‘(II) in the case that the Sec7 retary finds that more than 5 percent 

8 of Medicare Advantage plans sub9 mitted incomplete or inaccurate infor10 mation for three consecutive years, be11 ginning with the subsequent year, for 

12 all Medicare Advantage plans.’’. 

13 (c) MEDPAC REPORT.—Not later than 3 years after 

14 the date on which information is first required to be sub15 mitted pursuant to paragraph (3) of section 1852(c) of 

16 the Social Security Act (42 U.S.C. 1395w–122(c)), as 

17 added by section 2 (a), and paragraph (4) of such section 

18 1852(c), as added by subsection (a), the Medicare Pay19 ment Advisory Commission shall submit to Congress a re20 port on such information that includes a descriptive anal21 ysis of any information reported pursuant to such para22 graph. 


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1 SEC. 4. DATA ON COVERAGE DENIALS AND PRIOR AUTHOR2 IZATION REQUIREMENTS. 

3 (a) IN GENERAL.—Section 1852(c) of the Social Se4 curity Act (42 U.S.C. 1395w–22(c)), as amended by sec5 tions 2 and 3, is further amended by adding at the end 

6 the following new paragraph: 

7 ‘‘(5) DATA ON COVERAGE DENIALS AND PRIOR

8 AUTHORIZATION REQUIREMENTS.— 

9 ‘‘(A) IN GENERAL.—For each plan year 

10 beginning on or after January 1 of the second 

11 year beginning on or after the date of the en12 actment of this paragraph, with respect to ap13 plicable benefits described in subsection (a)(1), 

14 subsection (a)(3), and section 1860D–2, a 

15 Medicare Advantage organization offering a 

16 Medicare Advantage plan shall, in addition to 

17 any applicable information described in a pre18 vious paragraph, submit, not later than 6 

19 months after the end of the plan year, to the 

20 Secretary the following data, at the plan level 

21 and presented by coverage, service, or benefit 

22 type (as applicable), with respect Medicare Ad23 vantage eligible individuals enrolled under such 

24 plan during such plan year: 

25 ‘‘(i) The number of claims denied, 

26 presented by reason for the denial. 


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1 ‘‘(ii) The number and type of claims 

2 requiring prior authorization or 

3 precertification. 

4 ‘‘(iii) The average period between the 

5 initial submission of a claim for approval 

6 and the delivery of care. 

7 ‘‘(iv) The number and percentage of 

8 coverage denials appealed by service type. 

9 ‘‘(v) The number and percentage of 

10 prior authorizations or precertifications ap11 pealed. 

12 ‘‘(vi) The number of favorable deci13 sions that overturned the initial coverage 

14 determination upon appeal. 

15 ‘‘(vii) The average period between the 

16 formal initiation of appeal proceedings and 

17 final determination. 

18 ‘‘(viii) Total number and percentage 

19 of conversions of inpatient stays to out20 patient and observation status. 

21 ‘‘(ix) Information on each prior au22 thorization or precertification episode, in23 cluding the Medicare Advantage contract 

24 number, beneficiary Medicare ID, national 

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1 tion number, Healthcare Common Proce2 dure Coding System codes and modifiers, 

3 initial date of receipt, date of initial deci4 sion, action taken by the plan, denial code 

5 (if applicable), initial appeal date (if appli6 cable), and final appeal decision date (if 

7 applicable). 

8 ‘‘(x) Such other information as speci9 fied by the Secretary. 

10 ‘‘(B) DENIAL CODES AND ADDITIONAL

11 DATA ELEMENTS.—Not later than January 1 of 

12 the second year beginning on or after the date 

13 of the enactment of this paragraph, for pur14 poses of subparagraph (A)(ix), the Secretary 

15 shall establish— 

16 ‘‘(i) denial code categories and defini17 tions and provide to Medicare Advantage 

18 plans guidance on such categories and defi19 nitions; and 

20 ‘‘(ii) additional standardized data ele21 ments, as appropriate.’’. 

22 (b) FURTHER DISCLOSURES.—Section 1851(d)(4) of 

23 the Social Security Act (42 U.S.C. 1395w–21(d)(4)) is 

24 amended by adding at the end the following new subpara25 graph: 


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1 ‘‘(F) COVERAGE DENIALS AND PRIOR AU2 THORIZATIONS.—Information submitted by the 

3 plan under section 1852(c)(5), with respect to 

4 such year.’’. 

5 SEC. 5. QUALITY MEASURES. 

6 (a) IN GENERAL.—Section 1852(e)(3)(A) of the So7 cial Security Act (42 U.S.C. 1395w–22(e)(3)(A)) is 

8 amended— 

9 (1) in clause (i), by striking ‘‘and subject to 

10 subparagraph (B)’’ and inserting ‘‘and subject to 

11 clause (v) and subparagraph (B)’’; and 

12 (2) by adding at the end the following new 

13 clause: 

14 ‘‘(v) PLAN LEVEL DATA.—For each 

15 plan year beginning on or after January 1 

16 of the second year beginning on or after 

17 the date of the enactment of this clause, 

18 subject to section 1853(o)(6), data sub19 mitted under this subparagraph shall be at 

20 the plan level in addition to the contract 

21 level.’’. 

22 (b) APPLICATION TO STAR RATING SYSTEM.—Sec23 tion 1853(o)(4)(A) of the Social Security Act (42 U.S.C. 

24 1395w–23(o)(4)(A)) is amended by adding at the end the 

25 following new sentence: ‘‘For each plan year beginning on 


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1 or after January 1 of the second year beginning on or 

2 after the date of the enactment of the Medicare Advantage 

3 Consumer Protection and Transparency Act, subject to 

4 paragraph (6), the Secretary shall require reporting of 

5 data under section 1852(e) for, and apply under this sub6 section, quality measures at the plan level in addition to 

7 at the contract level.’’. 

8 SEC. 6. PROVIDER NETWORK INFORMATION. 

9 (a) IN GENERAL.—Section 1851(d)(5) of the Social 

10 Security Act (42 U.S.C. 1395w–21(d)(5)) is amended by 

11 adding at the end the following: ‘‘For each plan year be12 ginning on or after January 1 of the second year begin13 ning on or after the date of the enactment of the Medicare 

14 Advantage Consumer Protection and Transparency Act, 

15 the Secretary shall ensure such Internet site includes com16 plete and accurate information (to be updated at least 

17 quarterly) on providers of services and suppliers partici18 pating in the networks of Medicare Advantage plans and 

19 a portal that enables plans to update information on such 

20 site on the providers of services and suppliers participating 

21 in the networks of such plans, including any changes in 

22 such networks and whether such providers and suppliers 

23 are accepting new patients.’’. 

24 (b) DISCLOSURE BY PLANS.—Section 1851(d)(4) of 

25 the Social Security Act (42 U.S.C. 1395w–21(d)(4)), as 


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1 amended by section 4(b), is further amended by adding 

2 at the end the following new subparagraph: 

3 ‘‘(G) PROVIDER NETWORK INFORMA4 TION.—For each plan year beginning on or 

5 after January 1 of the second year beginning 

6 on or after the date of the enactment of this 

7 subparagraph, accurate information that is sub8 mitted in a machine readable format and that 

9 identifies all providers of services and suppliers 

10 participating in the network of the plan, includ11 ing all changes to such network that occur dur12 ing the plan year, and whether such providers 

13 and suppliers are accepting new patients.’’. 

Æ 


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