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. SCHA-
KOWSKY) introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to require 
complete and accurate data set submissions from Medi-
care Advantage organizations offering Medicare Advan-
tage plans under part C of the Medicare program to 
improve transparency, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Advantage 
Consumer Protection and Transparency Act’’. 
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SEC. 2. MEDICARE ADVANTAGE SUPPLEMENTAL BENEFITS 
DATA. 
(a) IN GENERAL.—Section 1852(c) of the Social Se-
curity Act (42 U.S.C. 1395w–122(c)) is amended by add-
ing at the end the following new paragraph: 
‘‘(3) SUPPLEMENTAL BENEFITS DATA.— 
‘‘(A) SUBMISSIONS
TO
SECRETARY.—For 
each plan year beginning on or after January 1 
of the second year beginning on or after the 
date of enactment of this paragraph, a Medi-
care Advantage organization offering supple-
mental benefits described in subsection (a)(3) 
under a Medicare Advantage plan shall submit 
(or, in the case of such an organization that 
contracts with an entity (such as a third-party 
contractor) to provide supplemental benefits in 
connection with such plan, require under such 
contract for the entity to submit), not later 
than 6 months after the end of the plan year, 
to the Secretary, in a clear, accurate, and 
standardized form in accordance with subpara-
graph (B) complete and accurate (as specified 
by the Secretary pursuant to subparagraph 
(B)) information, at the plan level and pre-
sented by coverage, service, or benefit type (as 
applicable), on such benefits offered under such 
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plan during the plan year, including regarding 
the following: 
‘‘(i) The type and nature of each sup-
plemental benefit so offered during such 
plan year. 
‘‘(ii) The number of Medicare Advan-
tage eligible individuals enrolled under plan 
during such plan year with coverage that 
enables access to such benefits. 
‘‘(iii) The number of Medicare Advan-
tage eligible individuals enrolled under the 
plan during such plan year who received a 
service with respect to each such supple-
mental benefit type so offered. 
‘‘(iv) The total plan and beneficiary 
expenditures made for such supplemental 
benefits, with respect to such plan year, 
excluding profits, administrative costs, and 
other overhead expenses. 
‘‘(v) The total beneficiary cost sharing 
for supplemental benefits, with respect to 
such plan year, reported in total bene-
ficiary expenditure and as a percentage of 
total expenditure. 
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‘‘(vi) All encounter data related to 
claims for supplemental benefits so offered, 
with respect to such plan year. 
‘‘(vii) All payment data, disaggregated 
by contributing payer, related to claims for 
supplemental benefits so offered, with re-
spect to such plan year. 
‘‘(viii) Such other information as spec-
ified by the Secretary. 
‘‘(B) REGULATIONS.—Not later than July 
1 of the first year beginning on or after the 
date of the enactment of this paragraph, for 
purposes of subparagraph (A), the Secretary 
shall, through rulemaking— 
‘‘(i) establish procedures to stand-
ardize the language used in describing sup-
plemental benefits (including categories of 
such benefits) and metrics; 
‘‘(ii) establish procedures to stand-
ardize the collection and evaluation of data 
under such subparagraph; 
‘‘(iii) analyze and publicly report, in 
common language, the standardized lan-
guage to be used by plans in describing 
supplemental benefits (including categories 
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of such benefits) in any materials intended 
for potential consumers, including mar-
keting materials, plan comparison tools 
under section 1851(d), and any other ma-
terials the Secretary deems appropriate; 
‘‘(iv) specify metrics and methods for 
determining 
whether 
information 
sub-
mitted under subparagraph (A) is complete 
and accurate, including by requiring such 
information include at least comparisons of 
supplemental benefit information between 
encounter 
records 
submitted 
under 
1852(c)(3)(A)(vi), aggregate data sub-
mitted under 1852(c)(3)(A)(i–v), spending 
data for types and categories of supple-
mental 
benefits 
submitted 
under 
1857(e)(4), and supplemental benefit infor-
mation submitted under 1854(a)(6)(A); 
and 
‘‘(v) determine categories or levels of 
incompleteness for plans that do not sub-
mit complete encounter data. 
In carrying out clause (iv), a Medicare Advan-
tage plan shall be treated as not submitting 
complete encounter data if the Secretary deter-
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subparagraph), has not submitted complete and 
accurate information, as required under section 
1852(c)(3), for each month during such plan 
year (until such month, if any, during such plan 
year during which the organization submits 
such complete and accurate information (as de-
termined in accordance with the metrics and 
methods 
specified 
pursuant 
to 
section 
1852(c)(3)(B))), the monthly payment amount 
specified in clauses (i), (ii), and (iii) of subpara-
graph (B), as applicable, shall be reduced by 5 
percent of the amount that would otherwise 
apply.’’. 
SEC. 3. MEDICARE ADVANTAGE ENCOUNTER DATA AC-
COUNTABILITY. 
(a) IN GENERAL.—Section 1852(c) of the Social Se-
curity Act (42 U.S.C. 1395w–122(c)), as amended by sec-
tion 2, is further amended by adding at the end the fol-
lowing new paragraph: 
‘‘(4) ENCOUNTER DATA ACCOUNTABILITY.— 
‘‘(A) SUBMISSIONS
TO
SECRETARY.—For 
each plan year beginning on or after January 1 
of the second year beginning on or after the 
date of the enactment of this paragraph, a 
Medicare Advantage organization offering a 
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Medicare Advantage plan shall, in accordance 
with the regulations promulgated pursuant to 
subparagraph (B), submit to the Secretary, not 
later than 6 months after the end of the plan 
year, complete and accurate (as specified by the 
Secretary pursuant to such regulations) pay-
ment data, disaggregated by plan and bene-
ficiary expenditure, and encounter data for all 
encounters covered through benefits under the 
original fee-for-service program defined under 
subsection (a)(1)(B) occurring during the plan 
year with respect to Medicare Advantage eligi-
ble individuals enrolled under such plan during 
such plan year. 
‘‘(B) REGULATIONS.—Not later than July 
1 of the first year beginning on or after the 
date of the enactment of this paragraph, for 
purposes of subparagraph (A), the Secretary 
shall, through rulemaking— 
‘‘(i) specify metrics and methods for 
determining 
whether 
information 
sub-
mitted under subparagraph (A) is complete 
and accurate, which shall include, as appli-
cable, at least comparisons between— 
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‘‘(I) encounter records submitted 
under this section; 
‘‘(II) patient assessment forms 
for home health (using information 
submitted through the Outcome and 
Assessment Information Set instru-
ment or a successor instrument), 
skilled nursing (using information 
submitted through the Minimum Data 
Set tool (or a successor tool)), and in-
patient rehabilitation services (using 
information submitted through the In-
patient Rehabilitation Facility Patient 
Assessment Instrument (or a suc-
cessor instrument)); 
‘‘(III) monthly dialysis indicators 
used for risk adjustment; 
‘‘(IV) Medicare Provider and 
Analysis Review data; 
‘‘(V) service utilization data sub-
mitted under section 1854(a)(6)(A); 
and 
‘‘(VI) any other data source or 
method as specified by the Secretary; 
and 
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‘‘(ii) determine categories or levels of 
incompleteness for Medicare Advantage 
plans that do not submit complete encoun-
ter data. 
In carrying out clause (ii), a Medicare Advan-
tage plan shall be treated as not submitting 
complete encounter data if the Secretary deter-
mines the plan has submitted less than 90 per-
cent of encounter data, including with respect 
to the data sources identified in clause (i). 
‘‘(C) PUBLIC REPORTING.—Beginning not 
later than July 1 of the second year beginning 
on or after the date of the enactment of this 
paragraph, the Secretary shall publicly report 
the data submitted pursuant to subparagraph 
(A).’’. 
(b) PENALTY
FOR
NOT
SUBMITTING
INFORMA-
TION.—Section 1853(a)(1) of the Social Security Act (42 
U.S.C. 1395w–23(a)(1)), as amended by section 2, is fur-
ther amended— 
(1) in subparagraph (B)— 
(A) in clause (i), by striking ‘‘(G), and 
(J)’’ and inserting ‘‘(G), (J), and (K)’’; 
(B) in clause (ii), by striking ‘‘(G), and 
(J)’’ and inserting ‘‘(G), (J), and (K)’’; and 
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(C) in clause (iii), by striking ‘‘subpara-
graph (J)’’ and inserting ‘‘subparagraphs (J) 
and (K)’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(J) ADJUSTMENT FOR NOT SUBMITTING 
ENCOUNTER DATA.— 
‘‘(i) IN GENERAL.—In the case of a 
Medicare Advantage plan offered by a 
Medicare Advantage organization that, 
with respect to a plan year (beginning on 
or after January 1 of the second year be-
ginning on or after the date of the enact-
ment of this subparagraph), has not sub-
mitted any encounter information under 
section 1852(c)(4), for each month during 
such plan year (until such month, if any, 
during such plan year during which the or-
ganization submits such information), the 
monthly payment amount specified in 
clauses (i) and (ii) of subparagraph (B) 
shall be reduced by 10 percent of the 
amount that would otherwise apply. 
‘‘(ii) REDUCTION
FOR
INCOMPLETE 
DATA SUBMITTED.—In the case of a Medi-
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care Advantage plan offered by a Medicare 
Advantage organization that, with respect 
to a plan year (beginning on or after Janu-
ary 1 of the second year beginning on or 
after the date of the enactment of this sub-
paragraph), has submitted encounter infor-
mation, 
as 
required 
under 
section 
1852(c)(4), but such information is not 
complete or is not accurate, as required 
under such section, for each month during 
such plan year (until such month, if any, 
during such plan year during which the or-
ganization submits such complete and ac-
curate information), the monthly payment 
amount specified in clauses (i), (ii), and 
(iii) of subparagraph (B), as applicable, 
shall be reduced by a percent specified by 
the Secretary (not to exceed 5 percent) of 
the amount that would otherwise apply. 
Such percent specified by the Secretary 
shall be based on the percentage of infor-
mation missing in the submission and de-
termined pursuant to rulemaking. 
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‘‘(iii) PROCESS.—In applying the re-
ductions under this subparagraph, the Sec-
retary— 
‘‘(I) shall provide public justifica-
tion for any percent reduction applied 
pursuant to clause (ii), including data 
used to arrive at the determination of 
the percent so applied; 
‘‘(II) may authorize an internal 
entity or contract with an external en-
tity to assist with carrying out sub-
clause (I) and determining any per-
cent reduction to be applied under 
clause (ii); and 
‘‘(III) shall establish a mecha-
nism for Medicare Advantage organi-
zations 
to 
appeal 
determinations 
under this subparagraph, with respect 
to such organization. 
‘‘(iv) COLLECTION OF DATA THROUGH 
MEDICARE
ADMINISTRATIVE
CONTRAC-
TORS.—The Secretary shall implement a 
mechanism requiring direct submission of 
provider claims to Medicare Administrative 
Contractors— 
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‘‘(I) for Medicare Advantage 
plans that submit incomplete or inac-
curate encounter information under 
this subparagraph for 2 consecutive 
years; and 
‘‘(II) in the case that the Sec-
retary finds that more than 5 percent 
of Medicare Advantage plans sub-
mitted incomplete or inaccurate infor-
mation for three consecutive years, be-
ginning with the subsequent year, for 
all Medicare Advantage plans.’’. 
(c) MEDPAC REPORT.—Not later than 3 years after 
the date on which information is first required to be sub-
mitted pursuant to paragraph (3) of section 1852(c) of 
the Social Security Act (42 U.S.C. 1395w–122(c)), as 
added by section 2 (a), and paragraph (4) of such section 
1852(c), as added by subsection (a), the Medicare Pay-
ment Advisory Commission shall submit to Congress a re-
port on such information that includes a descriptive anal-
ysis of any information reported pursuant to such para-
graph. 
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SEC. 4. DATA ON COVERAGE DENIALS AND PRIOR AUTHOR-
IZATION REQUIREMENTS. 
(a) IN GENERAL.—Section 1852(c) of the Social Se-
curity Act (42 U.S.C. 1395w–22(c)), as amended by sec-
tions 2 and 3, is further amended by adding at the end 
the following new paragraph: 
‘‘(5) DATA ON COVERAGE DENIALS AND PRIOR 
AUTHORIZATION REQUIREMENTS.— 
‘‘(A) IN
GENERAL.—For each plan year 
beginning on or after January 1 of the second 
year beginning on or after the date of the en-
actment of this paragraph, with respect to ap-
plicable benefits described in subsection (a)(1), 
subsection (a)(3), and section 1860D–2, a 
Medicare Advantage organization offering a 
Medicare Advantage plan shall, in addition to 
any applicable information described in a pre-
vious paragraph, submit, not later than 6 
months after the end of the plan year, to the 
Secretary the following data, at the plan level 
and presented by coverage, service, or benefit 
type (as applicable), with respect Medicare Ad-
vantage eligible individuals enrolled under such 
plan during such plan year: 
‘‘(i) The number of claims denied, 
presented by reason for the denial. 
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‘‘(ii) The number and type of claims 
requiring 
prior 
authorization 
or 
precertification. 
‘‘(iii) The average period between the 
initial submission of a claim for approval 
and the delivery of care. 
‘‘(iv) The number and percentage of 
coverage denials appealed by service type. 
‘‘(v) The number and percentage of 
prior authorizations or precertifications ap-
pealed. 
‘‘(vi) The number of favorable deci-
sions that overturned the initial coverage 
determination upon appeal. 
‘‘(vii) The average period between the 
formal initiation of appeal proceedings and 
final determination. 
‘‘(viii) Total number and percentage 
of conversions of inpatient stays to out-
patient and observation status. 
‘‘(ix) Information on each prior au-
thorization or precertification episode, in-
cluding the Medicare Advantage contract 
number, beneficiary Medicare ID, national 
provider identifier, provider tax identifica-
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tion number, Healthcare Common Proce-
dure Coding System codes and modifiers, 
initial date of receipt, date of initial deci-
sion, action taken by the plan, denial code 
(if applicable), initial appeal date (if appli-
cable), and final appeal decision date (if 
applicable). 
‘‘(x) Such other information as speci-
fied by the Secretary. 
‘‘(B) DENIAL
CODES
AND
ADDITIONAL 
DATA ELEMENTS.—Not later than January 1 of 
the second year beginning on or after the date 
of the enactment of this paragraph, for pur-
poses of subparagraph (A)(ix), the Secretary 
shall establish— 
‘‘(i) denial code categories and defini-
tions and provide to Medicare Advantage 
plans guidance on such categories and defi-
nitions; and 
‘‘(ii) additional standardized data ele-
ments, as appropriate.’’. 
(b) FURTHER DISCLOSURES.—Section 1851(d)(4) of 
the Social Security Act (42 U.S.C. 1395w–21(d)(4)) is 
amended by adding at the end the following new subpara-
graph: 
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‘‘(F) COVERAGE DENIALS AND PRIOR AU-
THORIZATIONS.—Information submitted by the 
plan under section 1852(c)(5), with respect to 
such year.’’. 
SEC. 5. QUALITY MEASURES. 
(a) IN GENERAL.—Section 1852(e)(3)(A) of the So-
cial Security Act (42 U.S.C. 1395w–22(e)(3)(A)) is 
amended— 
(1) in clause (i), by striking ‘‘and subject to 
subparagraph (B)’’ and inserting ‘‘and subject to 
clause (v) and subparagraph (B)’’; and 
(2) by adding at the end the following new 
clause: 
‘‘(v) PLAN
LEVEL
DATA.—For each 
plan year beginning on or after January 1 
of the second year beginning on or after 
the date of the enactment of this clause, 
subject to section 1853(o)(6), data sub-
mitted under this subparagraph shall be at 
the plan level in addition to the contract 
level.’’. 
(b) APPLICATION TO STAR RATING SYSTEM.—Sec-
tion 1853(o)(4)(A) of the Social Security Act (42 U.S.C. 
1395w–23(o)(4)(A)) is amended by adding at the end the 
following new sentence: ‘‘For each plan year beginning on 
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