Medicare Advantage Cost Transparency Act

119th Congress Introduced by Diana DeGette and 1 co-sponsor

Requires Medicare Advantage encounter data to include allowed amounts, beneficiary cost sharing, and at-home health risk assessment details from specified and non-specified entitie

Introduced in House

Medicare Advantage Cost Transparency Act (H.R. 9392)

Purpose

Introduced in the 119th Congress by Rep. Diana DeGette (with Rep. Joyce as co-sponsor).

The bill amends title XVIII of the Social Security Act to improve transparency by requiring additional information to be included in Medicare Advantage encounter data.

Target date: plan year beginning on or after January 1, 2027.

Key Provisions

New data requirement in MA encounter data (Section 1859(j)):

For each encounter data submission related to an item or service furnished to a beneficiary under a Medicare Advantage (MA) plan, the Secretary must ensure the data include:
(A) The allowed amount for the item or service.
(B) The amount of cost sharing (deductibles, copayments, and coinsurance) imposed for the item or service.
(C) At-home health risk assessment information from a specified assessment entity, if such an assessment was furnished to the individual before the item or service.
- Includes an indicator showing that the assessment was provided by a specified assessment entity.
(D) At-home health risk assessment information from an assessment entity not described in (C), with a separate indicator to distinguish this entity.

Definitions:

Assessment Entity: An entity focused on providing in-home health risk assessments, as specified by the Secretary.
Specified Assessment Entity: An assessment entity with respect to which the MA organization (or an ownership/control party) has an ownership/control interest, as defined by the statute (to be interpreted in line with existing ownership/控制 definitions).

Who Would Be Affected

Medicare Advantage organizations (MA plans) that submit encounter data.

Beneficiaries receiving items or services through MA plans, particularly those who have or receive at-home health risk assessments.

The Department of Health and Human Services (specifically the Centers for Medicare & Medicaid Services) would be responsible for implementing and enforcing the data reporting changes.

Potential Impact

Transparency and affordability data: By including the allowed amount and beneficiary cost sharing in encounter data, the measure aims to improve visibility into pricing and patient financial responsibility.

In-home health risk assessments: The bill integrates in-home risk assessment data into encounter records, which could affect how assessments are tracked and attributed to specific entities (specified vs. non-specified assessment entities).

Policy and oversight implications: The Secretary would define and regulate what constitutes a specified assessment entity and ensure consistent data collection across MA plans starting in 2027.

Administrative burden: MA plans may face increased reporting requirements and need to coordinate data from multiple assessment entities to populate the new fields.

Timeline and Procedural Notes

Effective date for data inclusion begins with plan years starting on or after January 1, 2027.

Referred to the House Committees on Ways and Means and Energy and Commerce for consideration.

Summary

The Medicare Advantage Cost Transparency Act seeks to enhance price and cost-sharing transparency in MA by mandating richer encounter data, including the allowed amount and beneficiary cost-sharing, plus pre-service at-home health risk assessment data from specified and non-specified assessment entities. The goal is to improve accountability and understanding of costs borne by beneficiaries, while establishing definitions and oversight for in-home assessment entities within the MA program.