CMS Pub. 100-16, ch. 7, § 30

The Medicare Advantage (MA) program provides Parts A and B services under Part C of Title

XVIII of the Social Security Act (“the Act”). CMS administers risk adjusted payments to MA

organizations in accordance with Subpart G of 42 CFR §422.304. This regulatory provision is

based on sections 1853, 1854, and 1858 of the Act. CMS risk adjusts Part C payments made to

MA plans under Section 1853(a) (3) of the Act; these rules are codified at 42 CFR 422.310.

CMS risk adjusts payments to PACE organizations under 1894(d) (2).

MA plans include MA-only plans, MA-PD plans, regional plans, employer group health plans,

and Special Needs Plans (SNPs). CMS risk adjusts certain demonstration plan payments, such as

the Part C payments made to the dual demonstration plans (Wisconsin Partnership Program,

MassHealth Senior Care Options, and Minnesota Senior Health Options and Minnesota

Disability Health Options), and Social Health Maintenance Organizations (SHMOs).

CMS risk adjusts Part D payments to Medicare Advantage Prescription Drugs plans (MA-PDs),

standalone Prescription Drug Plans (PDPs), and PACE organizations under 1860(d); these rules

are codified at 42 CFR 423.

40 - Role and Responsibilities of Plan Sponsors

(Rev. 118; Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012 (for ASC X12 5010); Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12:

January 1, 2012 (for ASC X12 5010))

MA organizations, PACE organizations, 1876 Cost HMOs/Competitive Medical Plans (CMPs),

and starting in 2012, Health Care Prepayment Plans (HCPPs) like the United Mine Workers of

America Health and Retirement Funds, must submit risk adjustment data, as required by CMS.

This section provides a high-level checklist of plan requirements. Detailed information about

risk adjustment data collection, submission, reporting, and validation are outlined in later

sections within this chapter.

Risk Adjustment Data Submission Requirements – Plan Sponsors (Medicare Advantage

Organizations (MAOs), PACE organizations, and 1876 Cost HMO/CMPs) must:

• Ensure the accuracy and integrity of risk adjustment data submitted to CMS. All

diagnosis codes submitted must be documented in the medical record and must be

documented as a result of a face-to-face visit. The diagnosis must be coded according to

International Classification of Diseases, (ICD) Clinical Modification Guidelines for

Coding and Reporting.

• Implement procedures to ensure that diagnoses are from acceptable data sources. The

only acceptable data sources are hospital inpatient facilities, hospital outpatient facilities,

and physicians. Plan sponsors are responsible for determining provider type based on the

source of the data.

• Submit the required data elements from acceptable data sources according to the coding

guidelines.

• Submit all required diagnosis codes for each beneficiary and submit unique diagnoses at

least once during the risk adjustment data-reporting period. Submitters must filter

diagnosis data to eliminate the submission of duplicate diagnosis clusters.

o For Part B-only beneficiaries enrolled in a plan, the plan sponsor must submit

diagnosis codes under the same rules as for a beneficiary with both Parts A and B.

The plan should also submit diagnosis codes for Part A services provided under a

non-Medicare contract.

If upon conducting an internal review of submitted diagnosis codes, the plan sponsor

determines that any diagnosis codes that have been submitted do not meet risk adjustment

submission requirements, the plan sponsor is responsible for deleting the submitted

diagnosis codes as soon as possible.

• Receive and reconcile CMS Risk Adjustment Reports in a timely manner. Plan sponsors

must track their submission and deletion of diagnosis codes on an ongoing basis.

• Once CMS calculates the final risk scores for a payment year, plan sponsors may request

a recalculation of payment upon discovering the submission of inaccurate diagnosis

codes that CMS used to calculate a final risk score for a previous payment year and that

had an impact on the final payment. Plan sponsors must inform CMS immediately upon

such a finding.