Humana Issues Public Comment on Centers for Medicare & Medicaid Services Notice

WASHINGTON, Dec. 22 -- Michael Hoak, assistant vice president for public policy at Humana Inc., Louisville, Kentucky, has issued a public comment on the Centers for Medicare and Medicaid Services notice entitled "Advance Notice of Methodological Changes for Calendar Year 2022 for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies - Part I, CMS-HCC Risk Adjustment Model". The comment was written on Nov. 30, 2020, and posted on Dec. 18, 2020:

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This letter is in response to the Centers for Medicare and Medicaid Services (CMS) request for comments on Advance Notice of Methodological Changes for CY 2022 for MA Capitation Rates, Part C and Part D Payment Policies as issued on October 30, 2020.

Humana Inc., headquartered in Louisville, Kentucky, is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. As one of the nation's top contractors for Medicare Advantage (MA) with more than 4.5 million members and Medicare Prescription Drug Plans (PDPs) with nearly 3.9 million members, we are distinguished by our nearly 30-year, long-standing, comprehensive commitment to Medicare beneficiaries across the United States. These beneficiaries - a large proportion of whom depend upon the Medicare Advantage program as their safety net and many in underserved areas - receive integrated, coordinated, quality, and affordable care through our plans.

Humana is also a direct provider of care for Medicare beneficiaries. We have a 40 percent ownership stake in Kindred at Home which is comprised of 777 home health, hospice and community care programs. Additionally, through joint-venture partnerships and alliances, Humana has interests in over 70 primary care centers in 21 states.

While we have provided more detailed comments below, we have highlighted several issues that we believe have the potential to significantly impact the future direction and growth of the Medicare Advantage program. This program remains the largest, most successful, comprehensive, and integrated care delivery model in Medicare.

Summary of Humana's Key Issues and Recommendations

* MA Coding Pattern Adjustment - We urge CMS to finalize its proposal to apply the statutory minimum MA coding pattern adjustment of 5.9 percent.

* Potential Change in the Schedule for Publication of the Rate Announcement for CY 2022 - Humana appreciates the early release of the Advance Notice and the potential early release of the Rate Announcement. In order to ensure that Medicare Advantage organizations (MAOs) can fully utilize this additional time to better prepare plan bids given the challenges and uncertainty associated with the COVID-19 pandemic, we urge CMS to promptly issue corresponding guidance crucial to constructing plan bids, including program and benefit parameters, bid instructions, and cost sharing levels.

* Full Transparency of COVID-19 Methodology and Assumptions - Humana appreciates the information already provided by CMS concerning various assumptions and results from the agency's estimates for the impact of COVID-19 on claims costs. We strongly encourage CMS to release all of the underlying assumptions and details behind these estimates so that MAOs can review the information and consider adjustments to the assumptions and methodologies to reflect in their projections of benefit expense.

* Implementation Guidance on Removal of Safe Harbor Protection of Prescription Drug Rebates - Humana urges CMS to provide implementation guidance as soon as possible on the Department of Health and Human Services (HHS) Office of the Inspector General's (OIG) recent changes to the safe harbor protection of prescription drug rebates in order to define how these changes should be applied in the context of the Part D program. It is imperative that MAOs and plan sponsors have this guidance in order to best support beneficiaries enrolled in the Part D Program during the transition to point-of-sale rebates and to inform bid development.

As always, we value this opportunity to provide comments and are pleased to answer any questions you may have with respect to the comments below. We hope that you consider our comments as constructive feedback aimed at ensuring that together we continue to advance our shared goals of improving the delivery of coverage and services in a sustainable, affordable manner to Medicare beneficiaries, focused on improving their total health care experience.

Sincerely,

Michael Hoak

Assistant Vice President, Public Policy

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Introduction: Notice of a Potential Change in the Schedule for Publication of the Rate Announcement for CY 2022

CMS has customarily published the Rate Announcement in April, preceded by Part I of the Advance Notice in December or January (for those policies for which a longer comment period was required) and Part II in February, to comply with the statutory deadlines set forth in the Social Security Act. However, for CY 2022, CMS is considering publishing the Rate Announcement earlier in 2021 in light of the challenges posed by the uncertainty associated with the COVID-19 pandemic for Medicare Advantage organizations, PACE organizations, and Part D sponsors.

Humana Comment: Humana appreciates CMS's consideration of the challenges and uncertainty associated with the COVID-19 pandemic and the additional time to prepare bids. We also understand CMS's desire to retain flexibility, including reserving the option to follow the typical April timeframe for publishing the CY 2022 Rate Announcement to allow CMS to incorporate additional, more recent data. While we appreciate the possibility of having information sooner, so that carriers may plan accordingly, we request that CMS communicate the date the Rate Announcement will be published in advance, along with a timeline outlining the publication dates for additional planned publications and impacts. Each publication related to the Rate Notice requires substantial hours of analysis and communication to many internal and external stakeholders. Advance notification of future publication dates would help ensure that MAOs can fully benefit from the additional time granted by CMS.

Advance Notice Part I

Sources of Diagnoses for Risk Score Calculation for CY 2022

For CY 2021, CMS will calculate risk scores for payment to MA organizations and certain demonstrations by adding 75% of the risk score calculated using risk adjustment eligible diagnoses identified from encounter data, FFS claims, and Risk Adjustment Processing System (RAPS) inpatient records with 25% of the risk score calculated using risk adjustment eligible diagnoses identified from RAPS data and FFS claims. For CY 2022, CMS proposes to calculate risk scores for payment to MA organizations and certain demonstrations using only risk adjustment eligible diagnoses identified from encounter data submitted by MA organizations and FFS claims, using the 2020 CMS-HCC model. Under its proposal for CY2022 risk adjustment, CMS is proposing two changes to the sources of diagnoses used to calculate risk scores: (1) discontinue use of RAPS inpatient diagnoses to supplement encounter/EDS data and (2) end the blending of encounter data-based and RAPS-based risk scores and move to using 100% of the risk score calculated using diagnoses from MA encounter data and FFS claims.

Humana comment: Humana supports CMS' proposal to discontinue the policy of supplementing diagnoses from encounter data with diagnoses from RAPS inpatient records. Humana also supports CMS' proposal to fully transition to 100% encounter data and FFS-based risk scores using the 2020 CMS-HCC Model.

Advance Notice Part II

Attachment I. Preliminary Estimates of the National Per Capita Growth Percentage and the National Medicare Fee-for-Service Growth Percentage for Calendar Year 2022

Section B. USPCC Estimates

CMS' estimates for the USPCCs for 2020 and subsequent years reflect the projected cost impacts related to the COVID-19 pandemic, including estimates for applicable costs related to any COVID-19 vaccine, and changes in utilization of health care services. These USPCCs also reflect estimated cost impacts of changes in MA coverage created by recent legislation. Section 6003 of the Families First Coronavirus Response Act (FFCRA) (Pub. L. 116-127), which amended section 1852(a)(1)(B) of the Act, prohibits MA organizations from requiring cost-sharing in excess of Medicare FFS cost-sharing for testing for COVID-19 and specified testing-related services during the public health emergency. According to CMS, this, in effect, eliminates MA cost-sharing for COVID-19 testing because there is no cost-sharing under Medicare FFS for the testing and there is no cost sharing for the specified testing-related services during the same period. Section 6003 also prohibits MA plans from applying prior authorization or any other utilization management requirement with respect to COVID-19 clinical diagnostic laboratory tests and specified COVID-19 testing-related services. In addition, Section 3713 of the CARES Act, which amended section 1852(a)(1)(B) of the Act, prohibits MA organizations from requiring cost-sharing in excess of Medicare FFS cost-sharing (which is zero) for a COVID-19 vaccine and its administration described in section 1861(s)(10)(A) of the Act; this limitation on cost sharing is not limited to the public health emergency and, therefore, will apply in 2022 regardless of whether the public health emergency declaration is still in place.

Humana comment: We fully acknowledge the extraordinary challenges and uncertainty inherent in projecting program costs in the midst of a pandemic. Given this uncertainty, we request that CMS, to the greatest extent possible, provide details regarding the sources of input behind the agency's assumptions, as well as the potential variability of these assumptions and impact on USPCC.

We applaud CMS for providing more detailed information on the agency's assumptions in recent stakeholder calls. For example, during the November 4th Stakeholder Call, Richard Coyle of CMS's Office of the Actuary (OACT) provided additional detail regarding the deferred utilization of care, citing a reduction in care in 2020, particularly in the second quarter, and OACT's expectation that 40-45 percent of that care would be provided at the end of 2020 and in 2021. Humana requests additional information about the determination of the 40-45 percent estimate, including assumptions by service category, timing of the care and detailed calculations so that we can better understand the impacts of this deferred treatment on the current estimates of 2020 and 2021 USPCCs.

During the Stakeholder Call, Mr. Coyle also provided the following assumptions underlying the projected 2022 cost of a COVID-19 vaccine: 52 percent utilization, $88 per dose cost (including $28 for administration), and 2 doses for each utilizer. In addition, during the Actuarial User Group Call, Mr. Coyle provided the following assumptions included in the restated 2021 USPCC: 32 percent utilization, $30 per dose cost (including $25 for administration), and 1.9 doses per utilizer. Humana requests that OACT provide the source data and additional detail behind the development of the above assumptions.

We are concerned that the 52 percent vaccine utilization rate assumed for 2022 could be insufficient to materially impact the prevalence of COVID-19 or associated changes to health care utilization patterns. Given the uncertainty regarding potential vaccination rates and the associated impact on the prevalence of COVID-19 and associated changes to health care utilization pattern, Humana requests that OACT, to the extent possible, provide additional information about their assumptions as to how the vaccine will impact COVID-19 prevalence and all utilization by service category, including numerical USPCC sensitivity analysis (in total or by service category) for different COVID-19 vaccine efficacy and utilization assumptions.

CMS states that the USPCCs and growth rates Advance Notice reflect the experience, data, and projections available as of the date of release and will be updated to reflect the experience, data, and projections available as of the Rate Announcement. With an early release of the CY 2022 Rate Announcement, the experience, data, and projections will be based on claims data through the third quarter of 2020, rather than through the fourth quarter of 2020 if the CY 2022 Rate Announcement were published under the later timeline. CMS acknowledges that this difference in data sources may impact year-to-year differences in estimates of projected USPCCs.

Humana comment: In the case of an early release, Humana requests that CMS include in the CY 2022 Rate Announcement detailed information regarding any adjustments made to account for having less data than is typical and any COVID-related adjustments.

Attachment II. Changes in the Payment Methodology for Medicare Advantage and PACE for CY 2022

Section A. MA Benchmark, Quality Bonus Payments, and Rebate

On November 20, 2020, CMS issued the Most Favored Nation (MFN) Model interim final rule (CMS- 5528-IFC). OACT estimates that the MFN model would reduce Medicare Advantage payments by approximately $49.6B over seven years.

Humana comment: In addition to the uncertainties imposed on plans with the finalization of the Rebate Rule, MAOs must also now plan for the financial impact associated with the MFN model. The interim final rule states that Medicare Advantage plans will not be able to benefit from the MFN pricing, however as a result of reduced FFS spending under the MFN Model the total payments to MA plans for Part B drugs over the seven-year course of the model will be substantially lower. Additionally, the 50 drugs included in the first year of the demonstration model alone encompass approximately 73 percent of Medicare Part B drug spending. Based off of the estimate provided by OACT, the impact of decreased spending associated with the MNF will impact MA payment beginning in 2023. We also anticipate that we will see PDP pricing impacts due to provider behavioral changes in 2021, including fee-for-service providers shifting to acquire drugs through retail pharmacies to avoid significantly disrupting prescribing habits. Given the magnitude and scale of the potential changes, we urge CMS to consider the implications of the model on the overall rate setting process and coordinate with plan actuaries well in advance of the CY 2023 bid cycle. This should include full transparency on the CY 2023 bid guidance, methods for making adjustments to the model for CY2023 and potential model recalibrations to adjust for the extraordinary impacts to the MA program.

B2. AGA Methodology

For Puerto Rico, CMS will continue to include five years (2015-2019) of historical claims and enrollment only for beneficiaries with Part A and Part B enrollment at the time of the dates of service for the FFS claim. While most Medicare beneficiaries are automatically enrolled in Part B and must opt out to decline it, beneficiaries in Puerto Rico must take affirmative action to opt-in to Part B coverage. CMS continues to believe it is appropriate to adjust the FFS rate calculation in Puerto Rico used to determine MA rates so that it is based on beneficiaries who are enrolled in both Part A and Part B in order to produce a more accurate projection of FFS costs per capita in Puerto Rico.

Humana comment: Humana supports the continuation of adjusting the FFS calculation in Puerto Rico used to determine MA rates so that it is based on beneficiaries who are enrolled in both Parts A and B.

B4. Additional Adjustment to FFS per Capita Costs in Puerto Rico

For the past five years, the Secretary has directed OACT to adjust the fee-for-service experience for beneficiaries enrolled in Puerto Rico to reflect the nationwide propensity of beneficiaries with zero claims. For the CY 2017-2021 Rate Announcements, OACT evaluated experience exclusively for beneficiaries who were enrolled in both Parts A and B and were not dually eligible for Veterans Affairs (VA) coverage. The study for setting the CY 2021 rates analyzed experience for calendar years 2014 through 2018 and only considered FFS beneficiaries enrolled mid-year. On average, 15.1 percent of Part A and Part B Puerto Rico FFS beneficiaries were found to have no Medicare Part A or Part B claim reimbursements per year. This compares to a nationwide, non-territory, proportion of 6.1 percent of FFS beneficiaries found to have no Medicare Part A claim reimbursements and no Medicare Part B claim reimbursements per year. Based on the Secretary's direction, the Puerto Rico FFS weighting of enrollment and risk scores for the zero-claim cohort was adjusted to reflect the nationwide proportion of zero-claim beneficiaries. The resulting impact was measured as an average increase in the standardized per-capita FFS costs in Puerto Rico of 4.7 percent for 2014 through 2018. Accordingly, a 4.7 percent adjustment was then applied to the pre-standardized Puerto Rico FFS rates supporting the CY 2021 ratebook development. CMS is considering whether a similar adjustment should be applied for 2022. OACT intends to perform an analysis that is similar to the prior analysis but with an updated five years of data: 2015-2019.

Humana comment: Humana appreciates CMS' ongoing efforts to improve the ratebook development methodology, and we recommend that CMS apply a similar adjustment for 2022.

CMS states that the agency is aware of stakeholder concerns regarding the FFS data used to establish MA benchmarks in Puerto Rico. As discussed in the CY 2017 Advance Notice, the Medicare statute requires that MA benchmarks be based on a county's average Medicare FFS per-capita cost, and there is no evidence that FFS costs in Puerto Rico are higher than the costs observed in the FFS claims data, and thus CMS believes there is no basis for overhauling Puerto Rico's MA benchmarks. As we stated in the CY 2017 and CY 2018 Rate Announcements, CMS believes that the FFS data in Puerto Rico is sufficient for establishing accurate MA benchmarks. The CY 2020 Advance Notice (page 21) and Rate Announcement (pages 27 and 28) included discussion and analysis of trends in the FFS data, and concluded that CMS' methodology of using five years of FFS experience mitigates annual fluctuations and anomalies in the data that may occur for a variety of reasons and provides for stability in the rates.

Humana comment: Humana appreciates CMS' consideration of public input and suggestions regarding methodological changes that may be appropriate. Humana supports using five years of FFS experience for each county as a way to mitigate annual fluctuations and anomalies in the data.

Section E. End Stage Renal Disease (ESRD) Rates

CMS is proposing to continue to apply in large part the same methodology as in previous years in calculating the MA ESRD state rates for CY2022.

Humana comments: Humana reiterates our concern that the changes proposed for CY2022 to account for the increased cost to MA organizations from enrollment of ESRD beneficiaries involve various forms of subsidization by non-ESRD members, such as ESRD subsidy, MOOP, and Part C cost sharing limits. For example, proposed changes in Part C cost sharing for "Inpatient Hospital Acute - 60 Days" would result in maximum cost sharing that exceeds 100 percent of the Medicare FFS cost sharing for individuals without ESRD./1

Rather than increasing costs for all non-ESRD beneficiaries, Humana recommends that CMS instead adjust the ESRD dialysis benchmarks to account for the significantly higher plan cost due to MOOP requirements.

As CMS has acknowledged, ESRD beneficiaries incur significantly higher claims costs, and incur more costs past the MOOP threshold, compared to non-ESRD beneficiaries./2

Accordingly, we recommend that CMS adjust the ESRD State Rates to reflect the impact of MOOP, an update that we believe the 21st Century Cures Act gives CMS the statutory authority to do. The intent of the 21st Century Cures Act is to permit the enrollment of ESRD beneficiaries into MA plans. Such an adjustment to payment benchmarks would more closely align with congressional intent by allowing MAOs to continue offering their current level of benefits as well as to maintain their broad geographic participation.

A recent Medicare Payment Advisory Commission (MedPAC) analysis/3 shows that 39 percent of MA contracts (representing 44 percent of dialysis enrollees) have costs for ESRD patients that exceed their revenue. A further 36 percent of contracts (representing 35 percent of enrollees) have a cost to revenue ratio of between.9 and 1.0, indicating that their costs are within 10 percent of their revenue. The MedPAC analysis excludes administrative costs from this calculation implying that a portion, maybe all, of these contracts are likely to have costs exceeding revenue if administrative costs were accounted for. Further, the MedPAC analysis shows that MA plans are paying on average 114 percent of the Medicare rate for dialysis treatments. MedPAC indicates that these higher payments are due to ownership concentration among dialysis providers and the negotiation power that results from industry concentration. Analysis of ESRD costs and revenue/4 shows that in 10 of the top 15 metropolitan areas, as measured by the number of ESRD beneficiaries, the ESRD benchmark payment amount is between 2 percent and 12 percent lower than FFS costs. Humana recommends that CMS consider these other factors when evaluating the need for adjustments to MA plan benchmarks.

Section G. MA Employer Group Waiver Plans (EGWPs)

CMS intends to continue waiving the Bid Pricing Tool bidding requirements for all MA employer/union-only group waiver plans (EGWPs) for 2022. As a condition of the waiver of the bidding requirements and the waivers otherwise provided to EGWPs, CMS will establish payment amounts using the same methodology for 2022 as was used for 2021.

In connection with the continuation of this waiver, for 2022, CMS will continue to use the payment methodology implemented for MA EGWPs, as finalized in the CY 2021 Rate Announcement, with one change. For 2022, we propose to change the methodology for setting MA EGWP rates, specifically the enrollment data used to weight the bid-to-benchmark ratios, depending on the timing of the release of the CY 2022 Rate Announcement.

The earlier release of the CY 2022 Rate Announcement will require that CMS use January 2021 enrollment data as of the January payment month for the purpose of weighting plan bids when calculating B2B ratios. In previous years, CMS used February enrollment data as of the February payment month. If CMS publishes the Rate Announcement in the later timeframe, the agency will continue to use the February 2021 enrollment data as of the February payment month in the calculation methodology. CMs states that the use of the February 2021--as opposed to the January 2021--enrollment data will allow the agency to use enrollment that will have fewer retroactive adjustments in the following months. This is because January enrollment reflects larger changes in plan enrollment than other months as a result of open enrollment, and there are more retroactive adjustments to January enrollment than for other payment months. Therefore, using the February enrollment will affect the weighting used to calculate B2B ratios. CMS believes that the benefit of an early announcement of MA rates for CY 2022 could outweigh the benefit of using the later data.

Humana comment: Humana supports the agency's proposal to continue using the CY 2021 MA EGWP payment methodology in CY 2022. We also support modifying the enrollment data used to weight B2B ratios based on the timing of the Rate Announcement release and understand the desire to balance the benefits of an earlier release with the accuracy of the B2B ratios.

Additionally, many large group renewals and prospects interested in MA EGWPs seek quotes from EGWP sponsors prior to the release of the bid-to-benchmark ratios in April. In order to provide groups more accurate quotes, we recommend that OACT publish preliminary 2023 bid-to-benchmark ratios with the early preview in November 2021 or with Part I of the Advance Notice in December 2021, based upon estimated 2022 membership weights. In addition, we recommend that CMS publish revised 2023 estimates with Part II of the Advance Notice, in February 2022, using preliminary actual 2022 membership weights would also be appreciated.

We acknowledge that the use of preliminary membership weights may cause initial B2B estimates to differ from the final values. However, we believe that incorporating initial weights with finalized values from Individual bid submissions will account for the vast majority of change in B2B ratios between coverage years. Our expectation is that changes in B2B ratios between coverage years is primarily attributable to changes in Individual bid submissions and not membership weights.

For 2022, CMS will continue the existing policy of permitting MA EGWPs to buy down Part B premiums for their enrollees using a portion of the Part C payment.

Humana comment: We strongly support CMS' proposal to allow MA EGWPs to reduce beneficiary costs by buying down Part B premiums, as this will lead to more consistency between individual and group MA plans.

As in 2020 and 2021, MA EGWPs will be subject to the same maximum CY 2022 Part B buy-down amount as non-EGWP plans. That is, EGWPs may only buy down the Part B premium up to the maximum amount displayed in the CY 2022 MA Bid Pricing Tool Worksheet 6. Additionally, as with non-EGWP plans, the Part B premium buy-down amount cannot vary among beneficiaries enrolled in an EGWP. The Part B buy-down amount applies to every beneficiary under the plan ID. Therefore, if an EGWP would like to reduce the Part B premium for one employer group under the plan ID by $5 and reduce the Part B premium for another employer group by $10, then two separate EGWP plan IDs would need to be established/utilized. As an example, the Plan Benefit Package (PBP) for plan 801 would contain a $5 buy-down amount and the PBP for plan 802 would contain a $10 buy-down amount.

Humana comment: Group quoting occurs throughout the year, with the arrangements typically finalized after the initial submission of PBPs in June. In 2016 and prior years when a Part B buy-down was previously permitted, a component of these arrangements has been the Part B buy-down amount. Given the uncertainty around which Part B buy-down amount may ultimately be agreed upon, multiple PBPs were filed with only differing Part B buy-down amounts. To minimize potential increases in the number of PBPs, Humana recommends that CMS establish a process using segment ID to facilitate additional flexibility with Part B buy-downs. Each segment ID would correspond to the amount of Part B buy-down, established as a whole dollar, up to the same maximum Part B buy-down amount as non-EGWP plans. However, a PBP for each unique segment ID would not be filed (only the segment "XYZ" would be filed). This would allow EGWP carriers to offer a range of Part B buy-down amounts, without having to file additional PBPs.

Humana understands that there may be system limitations or other operational considerations in pursuing this option, and we stand ready to partner with CMS to determine and implement the necessary changes to facilitate the implementation of this proposal for plan year 2022.

The Advance Notice states that with respect to EGWPs, "CMS will continue to waive the requirement that MA EGWPs must specify how they are allocating MA rebate dollars for 2022. However, the limits in Sec. 422.266 on how the MA rebate may be used have not been waived and therefore continue to apply for EGWPs." Humana comment: Humana requests that CMS directly address so-called "gainshare" arrangements in which employer groups request payments from MA Organizations based on Medical Loss Ratio or other standards. In some instances, these payments may come from funds CMS provides to MA plans. CMS' prior statements have given rise to significant confusion and disputes as to the applicable requirements. Accordingly, we are requesting that CMS provide additional information relevant to these arrangements: 1. Most importantly, CMS should directly address whether a portion of the CMS payments to MA EGWPs may be paid to employer groups. Does the statement that the requirements of 42 CFR Sec. 422.266 have not been waived mean that MA EGWPs are prohibited from using dollars received from CMS to make gainsharing payments to employer groups?

2. We are also requesting that CMS provide additional technical information about its waivers. In particular, we are requesting that CMS clarify and specify the statutory and regulatory provisions it has waived.

a. CMS should confirm whether it has waived the requirements of 42 USC Sec. 1395w-1854(b)(1)(C)(i) of the Social Security Act, which provides that "[t]he MA plan shall provide to the enrollee a monthly rebate" equal to a percentage of the savings. If not, CMS should say so expressly.

b. CMS should confirm which statutory and regulatory provisions it is referring to in stating that "CMS will continue to waive the requirement that MA EGWPs must specify how they are allocating MA rebate dollars for 2022." Does this waiver refer to 42 CFR Sec. 422.254(d), which provides that MA organizations "must inform CMS how the plan will distribute the beneficiary rebate among the options described at Sec. 422.266(b)?" Section I. CMS-HCC Risk Adjustment Model for CY 2022

For CY 2022, CMS is proposing to fully phase in the CMS-Hierarchical Condition Categories (HCC) model that was first implemented for CY 2020 (i.e., the 2020 CMS-HCC model), thereby calculating 100% of the risk score using the 2020 CMS-HCC model. In addition, CMS proposes to calculate risk scores for payment to MA organizations and certain demonstrations, including MMPs, using only risk adjustment-eligible diagnoses identified from encounter data and FFS claims for CY 2022.

Humana comment: Humana supports CMS' proposal to discontinue the policy of supplementing diagnoses from encounter data with diagnoses from RAPS inpatient records. Humana also supports CMS' proposal to fully transition to 100% encounter data and FFS-based risk scores using the 2020 CMS-HCC Model.

Section J. ESRD Risk Adjustment Models for CY 2022

Consistent with the proposal in Part I of the CY 2022 Advance Notice for the Part C risk adjustment model, for CY 2022, CMS is proposing to fully phase in the 2020 ESRD models. In addition to calculating 100% of the risk score using the 2020 ESRD models, CMS proposes to calculate risk scores for payment to MA organizations and certain demonstrations using only risk adjustment-eligible diagnoses from encounter data and FFS claims.

Humana comment: Humana supports CMS' proposal to discontinue the policy of supplementing diagnoses from encounter data with diagnoses from RAPS inpatient records. Humana also supports CMS' proposal to fully transition to 100% encounter data and FFS-based risk scores using the 2020 CMS-HCC Model.

View full comment at: https://downloads.regulations.gov/CMS-2020-0093-0091/attachment_2.pdf

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Footnotes:

1/ CMS Memorandum: Contract Year 2021 Part C Benefits Review and Evaluation. Kathryn A. Coleman, February 6, 2020.

2/ Ibid.

3/ MedPAC. Medicare Advantage payment and access for enrollees with end-stage renal disease; November 10, 2020. http://www.medpac.gov/docs/default-source/meeting-materials/ma-and-esrd-medpac-nov-2020.pdf?sfvrsn=0

4/ Avalere. MA plans may be paid below actual ESRD patients' costs in large metropolitan areas in 2021. December 9, 2019. https://avalere.com/insights/medicare-advantage-plans-may-be-paid-below-actual-esrd-patients-costs-in-large-metropolitan-areas-in-2021

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The notice can be viewed at: https://beta.regulations.gov/document/CMS-2020-0093-0002

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