Medicare Advantage Consumer Protection and Transparency Act
Bill: H.R.9019 | Sponsor: Rep. Porter, Katie (D-CA)
Policy area: Health

Summary:
Medicare Advantage Consumer Protection and Transparency Act
This bill generally requires Medicare Advantage organizations to report additional information to the Centers for Medicare & Medicaid Services, including supplemental plan benefits, encounter data, and the number of coverage denials and prior authorization requests. Failure to comply with the bill's requirements may result in payment reductions.

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.

    Be it enacted by the Senate and House of Representatives 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''.

SEC. 2. MEDICARE ADVANTAGE SUPPLEMENTAL BENEFITS DATA.

    (a) In General.--Section 1852(c) of the Social Security Act (42 
U.S.C. 1395w-122(c)) is amended by adding 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 Medicare Advantage organization offering 
                supplemental 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 subparagraph (B) 
                complete and accurate (as specified by the Secretary 
                pursuant to subparagraph (B)) information, at the plan 
                level and presented by coverage, service, or benefit 
                type (as applicable), on such benefits offered under 
                such plan during the plan year, including regarding the 
                following:
                            ``(i) The type and nature of each 
                        supplemental benefit so offered during such 
                        plan year.
                            ``(ii) The number of Medicare Advantage 
                        eligible individuals enrolled under plan during 
                        such plan year with coverage that enables 
                        access to such benefits.
                            ``(iii) The number of Medicare Advantage 
                        eligible individuals enrolled under the plan 
                        during such plan year who received a service 
                        with respect to each such supplemental 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 beneficiary 
                        expenditure and as a percentage of total 
                        expenditure.
                            ``(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 respect 
                        to such plan year.
                            ``(viii) Such other information as 
                        specified 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 standardize 
                        the language used in describing supplemental 
                        benefits (including categories of such 
                        benefits) and metrics;
                            ``(ii) establish procedures to standardize 
                        the collection and evaluation of data under 
                        such subparagraph;
                            ``(iii) analyze and publicly report, in 
                        common language, the standardized language to 
                        be used by plans in describing supplemental 
                        benefits (including categories of such 
                        benefits) in any materials intended for 
                        potential consumers, including marketing 
                        materials, plan comparison tools under section 
                        1851(d), and any other materials the Secretary 
                        deems appropriate;
                            ``(iv) specify metrics and methods for 
                        determining whether information submitted 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 
                        submitted under 1852(c)(3)(A)(i-v), spending 
                        data for types and categories of supplemental 
                        benefits submitted under 1857(e)(4), and 
                        supplemental benefit information submitted 
                        under 1854(a)(6)(A); and
                            ``(v) determine categories or levels of 
                        incompleteness for plans that do not submit 
                        complete encounter data.
                In carrying out clause (iv), a Medicare Advantage plan 
                shall be treated as not submitting complete encounter 
                data if the Secretary determines the plan has submitted 
                less than 90 percent of encounter data, including with 
                respect to the data sources identified in clause 
                (ii).''.
    (b) Penalty for Not Submitting Information.--Section 1853(a)(1) of 
the Social Security Act (42 U.S.C. 1395w-23(a)(1)) is amended--
            (1) in subparagraph (B)--
                    (A) in clause (i), by striking ``subparagraphs (F) 
                and (G)'' and inserting ``subparagraphs (F), (G), and 
                (J)'';
                    (B) in clause (ii), by striking ``subparagraphs (F) 
                and (G)'' and inserting ``subparagraphs (F), (G), and 
                (J)''; and
                    (C) in clause (iii), by inserting ``and (if 
                applicable) under subparagraph (J)'' after 
                ``subparagraph (C)''; and
            (2) by adding at the end the following new subparagraph:
                    ``(J) Adjustment for not submitting supplemental 
                benefit information.--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 
                beginning on or after the date of the enactment of this 
                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 determined 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 subparagraph (B), as 
                applicable, shall be reduced by 5 percent of the amount 
                that would otherwise apply.''.

SEC. 3. MEDICARE ADVANTAGE ENCOUNTER DATA ACCOUNTABILITY.

    (a) In General.--Section 1852(c) of the Social Security Act (42 
U.S.C. 1395w-122(c)), as amended by section 2, is further amended by 
adding at the end the following 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 
                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) payment data, disaggregated by plan and 
                beneficiary 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 eligible 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 submitted under 
                        subparagraph (A) is complete and accurate, 
                        which shall include, as applicable, at least 
                        comparisons between--
                                    ``(I) encounter records submitted 
                                under this section;
                                    ``(II) patient assessment forms for 
                                home health (using information 
                                submitted through the Outcome and 
                                Assessment Information Set instrument 
                                or a successor instrument), skilled 
                                nursing (using information submitted 
                                through the Minimum Data Set tool (or a 
                                successor tool)), and inpatient 
                                rehabilitation services (using 
                                information submitted through the 
                                Inpatient Rehabilitation Facility 
                                Patient Assessment Instrument (or a 
                                successor instrument));
                                    ``(III) monthly dialysis indicators 
                                used for risk adjustment;
                                    ``(IV) Medicare Provider and 
                                Analysis Review data;
                                    ``(V) service utilization data 
                                submitted under section 1854(a)(6)(A); 
                                and
                                    ``(VI) any other data source or 
                                method as specified by the Secretary; 
                                and
                            ``(ii) determine categories or levels of 
                        incompleteness for Medicare Advantage plans 
                        that do not submit complete encounter data.
                In carrying out clause (ii), a Medicare Advantage plan 
                shall be treated as not submitting complete encounter 
                data if the Secretary determines the plan has submitted 
                less than 90 percent 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 Information.--Section 1853(a)(1) of 
the Social Security Act (42 U.S.C. 1395w-23(a)(1)), as amended by 
section 2, is further 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
                    (C) in clause (iii), by striking ``subparagraph 
                (J)'' and inserting ``subparagraphs (J) and (K)''; and
            (2) by adding at the end the following new subparagraph:
                    ``(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 beginning on or after the date 
                        of the enactment of this subparagraph), has not 
                        submitted 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 organization 
                        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 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 beginning on or after the date of the 
                        enactment of this subparagraph), has submitted 
                        encounter information, 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 organization submits 
                        such complete and accurate 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 information 
                        missing in the submission and determined 
                        pursuant to rulemaking.
                            ``(iii) Process.--In applying the 
                        reductions under this subparagraph, the 
                        Secretary--
                                    ``(I) shall provide public 
                                justification 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 
                                entity to assist with carrying out 
                                subclause (I) and determining any 
                                percent reduction to be applied under 
                                clause (ii); and
                                    ``(III) shall establish a mechanism 
                                for Medicare Advantage organizations to 
                                appeal determinations under this 
                                subparagraph, with respect to such 
                                organization.
                            ``(iv) Collection of data through medicare 
                        administrative contractors.--The Secretary 
                        shall implement a mechanism requiring direct 
                        submission of provider claims to Medicare 
                        Administrative Contractors--
                                    ``(I) for Medicare Advantage plans 
                                that submit incomplete or inaccurate 
                                encounter information under this 
                                subparagraph for 2 consecutive years; 
                                and
                                    ``(II) in the case that the 
                                Secretary finds that more than 5 
                                percent of Medicare Advantage plans 
                                submitted incomplete or inaccurate 
                                information for three consecutive 
                                years, beginning 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 submitted 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 Payment Advisory Commission 
shall submit to Congress a report on such information that includes a 
descriptive analysis of any information reported pursuant to such 
paragraph.

SEC. 4. DATA ON COVERAGE DENIALS AND PRIOR AUTHORIZATION REQUIREMENTS.

    (a) In General.--Section 1852(c) of the Social Security Act (42 
U.S.C. 1395w-22(c)), as amended by sections 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 enactment of this paragraph, with 
                respect to applicable 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 previous 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 Advantage eligible 
                individuals enrolled under such plan during such plan 
                year:
                            ``(i) The number of claims denied, 
                        presented by reason for the denial.
                            ``(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 appealed.
                            ``(vi) The number of favorable decisions 
                        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 outpatient 
                        and observation status.
                            ``(ix) Information on each prior 
                        authorization or precertification episode, 
                        including the Medicare Advantage contract 
                        number, beneficiary Medicare ID, national 
                        provider identifier, provider tax 
                        identification number, Healthcare Common 
                        Procedure Coding System codes and modifiers, 
                        initial date of receipt, date of initial 
                        decision, action taken by the plan, denial code 
                        (if applicable), initial appeal date (if 
                        applicable), and final appeal decision date (if 
                        applicable).
                            ``(x) Such other information as specified 
                        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 purposes of subparagraph (A)(ix), the 
                Secretary shall establish--
                            ``(i) denial code categories and 
                        definitions and provide to Medicare Advantage 
                        plans guidance on such categories and 
                        definitions; and
                            ``(ii) additional standardized data 
                        elements, 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 subparagraph:
                    ``(F) Coverage denials and prior authorizations.--
                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 Social 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 submitted under this 
                        subparagraph shall be at the plan level in 
                        addition to the contract level.''.
    (b) Application to Star Rating System.--Section 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 or after January 1 of the second year beginning on or 
after the date of the enactment of the Medicare Advantage Consumer 
Protection and Transparency Act, subject to paragraph (6), the 
Secretary shall require reporting of data under section 1852(e) for, 
and apply under this subsection, quality measures at the plan level in 
addition to at the contract level.''.

SEC. 6. PROVIDER NETWORK INFORMATION.

    (a) In General.--Section 1851(d)(5) of the Social Security Act (42 
U.S.C. 1395w-21(d)(5)) is amended by adding at the end the following: 
``For each plan year beginning on or after January 1 of the second year 
beginning on or after the date of the enactment of the Medicare 
Advantage Consumer Protection and Transparency Act, the Secretary shall 
ensure such Internet site includes complete and accurate information 
(to be updated at least quarterly) on providers of services and 
suppliers participating in the networks of Medicare Advantage plans and 
a portal that enables plans to update information on such site on the 
providers of services and suppliers participating in the networks of 
such plans, including any changes in such networks and whether such 
providers and suppliers are accepting new patients.''.
    (b) Disclosure by Plans.--Section 1851(d)(4) of the Social Security 
Act (42 U.S.C. 1395w-21(d)(4)), as amended by section 4(b), is further 
amended by adding at the end the following new subparagraph:
                    ``(G) Provider network information.--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 
                subparagraph, accurate information that is submitted in 
                a machine readable format and that identifies all 
                providers of services and suppliers participating in 
                the network of the plan, including all changes to such 
                network that occur during the plan year, and whether 
                such providers and suppliers are accepting new 
                patients.''.
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