CMS has given itself another year to finalize a proposal to begin using an extrapolation methodology in recovering overpayments from Medicare Advantage organizations. The Trump administration in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said it planned to extrapolate the results of Risk Adjustment Data Validation Audits, starting with 2011 contract-level audits, and not apply a “fee-for-service adjuster” to account for inaccurate diagnosis codes in FFS Medicare data used to calibrate the MA risk adjustment model. In a Federal Register notice published on Oct. 21, CMS cited “exceptional circumstances” for exceeding the statutory three-year timeline and explained that it received extensive public comments on the proposal and the FFS Adjuster study that it released just prior to publishing the November 2018 proposed rule. CMS said it plans to publish the final rule by Nov. 1, 2022.

As Congressional lawmakers attempt to whittle down President Joe Biden’s $3.5 trillion budget reconciliation package that includes expanding Medicare benefits, Sens. Kyrsten Sinema (D-Ariz.) and Tim Scott (R-S.C.) are leading a bipartisan effort to protect the Medicare Advantage program from potential cuts. “Payment stability is critical to protecting and strengthening this popular choice for seniors, particularly since these seniors have paid into the Medicare program and expect to continue to receive the excellent, reasonably priced care offered by MA,” a group of 13 senators wrote to CMS Administrator Chiquita Brooks-LaSure. “We stand ready to protect MA from payment cuts, which could lead to higher costs and premiums, reduce vital benefits, and undermine advances made to improve health outcomes and health equity for MA enrollees.” Sinema has previously expressed opposition to prescription drug pricing proposals, such as giving Medicare the authority to negotiate drug prices, in the House and Senate versions of the legislation. Trade groups Better Medicare Alliance and AHIP cheered the move to protect MA. AHIP in August released a paper prepared by Wakely that estimated plans would have an average of 48% to 73% fewer rebate dollars to fund supplemental benefits if Congress adds dental, vision and hearing benefits without adjusting the MA benchmark.

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