Proposals Related to: Risk adjustment
Medicare’s payments to MA plans are adjusted to reflect the expected cost of providing care to an enrollee based on characteristics such as age, prior health conditions, and whether they are disabled, reside in an institution, or receive Medicaid benefits. Because risk scores are based on data for beneficiaries in original Medicare, this risk-adjustment system reflects the diagnosis coding patterns and predicted costs of that program. Over time, analysts have found that enrollees in MA plans have higher “coding intensity” (more diagnosis codes or higher severity of condition codes) compared with beneficiaries of similar health in original Medicare. Under original Medicare, providers have less incentive to code diagnoses. Currently, the law requires CMS to lower MA payments to reflect some but not all of the estimated differential in coding intensity between enrollees in MA versus in original Medicare. Some MA plan sponsors use chart reviews and health risk assessments more extensively than others, which leads to inequities in payments across MA organizations. CMS conducts a limited number of risk-adjustment data validation (RADV) audits, some of which have found a lack of support for diagnoses among MA enrollees’ medical records. Proposals in this category would change how CMS adjusts for coding intensity or make other changes to the MA risk-adjustment process.
NOTE: Entries with grey backgrounds are Georgetown estimates. Entries with white backgrounds are either descriptive information or analysis made by or for the proposal authors.
| Proposal | Effects on beneficiaries | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Short description | Category | Author | Federal savings (-$) or costs (+$) | Access to plans | Enrollee costs | Supplemental benefits | Part B premiums | Other affected stakeholders | |
Key:
- Federal savings or costs. When available, we provide original estimates from source materials by the proposal author(s) or from the Congressional Budget Office. Authors prepared estimates for some proposals at a time when plan enrollment and payments differ from today, and thus estimates of savings or costs should be interpreted cautiously. When no author’s estimate was available, Georgetown provided an estimate, as indicated by grey highlighting. Click Details for more information about savings or costs for a specific proposal.
Estimates in source materials prepared by the author(s) cover different numbers of years and windows of time. To give website users a consistent sense of magnitude, we categorized proposals by whether its estimate was approximately less than $10 billion over 5 years or greater than or equal to that amount. Thus, in this column,- +$ indicates anticipated costs to the federal government of less than $10 billion over 5 years.
- +$$ indicates anticipated costs of $10 billion or more over 5 years.
- –$ indicates anticipated savings to the federal government of less than $10 billion over 5 years.
- –$$ indicates anticipated savings of $10 billion or more over 5 years.
- We list a question mark for proposals in which the author(s) would need to specify more detail to estimate federal spending.
- Effects on beneficiaries. When available, the estimate was provided by the proposal author(s) within the cited source materials. When no author’s estimate was available, Georgetown provided an estimate, as indicated by grey highlighting. In the four columns under this header,
- Up arrows indicate anticipated greater access to plans, higher costs (premiums and cost sharing) for plan enrollees, more availability of extra benefits, or higher Part B premiums applicable to all beneficiaries.
- Down arrows indicate the reverse effects.
- Combined up and down arrows indicate mixed effects, such as up for some categories of beneficiaries and down for others.
- Categories may also be reported as “minimal or no effect” or “not applicable.”
- We list a question mark for proposals in which the author(s) would need to specify more detail to estimate effects on beneficiaries.
- Click Details for more information about beneficiary effects for a specific proposal.
- Other affected stakeholders. This column reports any stakeholders other than Medicare beneficiaries likely to be affected significantly by the proposal. Click Details for more information about a specific proposal.