GAO: CMS Lacks Encounter Data for MA Supplemental Benefits
Confusion about CMS guidance and difficulties with procedure codes have led to limited encounter data for Medicare Advantage supplemental benefits.
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- Nearly all Medicare Advantage plans offered supplemental benefits in 2022, but CMS received limited encounter data from the plans, a report from the Government Accountability Office (GAO) found.
GAO analyzed plan benefit data for almost 4,000 Medicare Advantage plans across the country to determine the supplemental benefits plans offered in 2022 and the information CMS had on beneficiaries’ use of the benefits.
GAO also reviewed CMS regulations and guidance and interviewed officials from CMS and six Medicare Advantage plans.
In 2022, all but one Medicare Advantage plan reviewed in the report offered at least one supplemental benefit that is not covered under traditional Medicare. Traditional health-related benefits, including vision (98 percent) and hearing (94 percent), were the most common benefits offered.
Starting in 2019, plans could offer benefits that focus on reducing avoidable healthcare use. In 2020, plans could newly provide benefits aimed at improving or maintaining the health or function of beneficiaries with chronic illnesses.
Fewer Medicare Advantage offered these newer benefits in 2022, the report found. Seventeen percent of plans provided in-home support services, and 6 percent of plans offered support for beneficiary caregivers, both of which are included in the benefits group first allowed in 2019.
Within the second group of new benefits, 15 percent of plans offered food and produce benefits, while 7 percent offered meals beyond a limited basis.
Medicare Advantage plans are required to submit encounter data to CMS, which details how often beneficiaries utilize supplemental benefits and the impact they have on beneficiaries’ health. Per CMS regulations, encounter data must include the procedure code for the benefit provided, which beneficiaries used it, who provided it, and the dates of service.
However, the GAO report found that CMS had limited encounter data on supplemental benefits from Medicare Advantage plans.
The limited data submission may stem from mixed interpretations of CMS guidance. According to the report, CMS guidance on encounter data does not explicitly mention data submission for supplemental benefits. But the guidance says plans must submit encounter data for each benefit provided to members.
CMS officials said that the requirement includes supplemental benefits and does not differentiate between supplemental and traditional Medicare benefits.
However, officials from two Medicare Advantage organizations told GAO they are not required to submit encounter data for some supplemental benefits. Another official said they do not have to submit encounter data for any supplemental benefits. Meanwhile, officials from one plan said they are required to submit data for all supplemental benefits.
Encounter data on supplemental benefits may also be limited due to procedure code difficulties, which make it hard to collect and submit the data. According to CMS and Medicare Advantage plan officials, there are no procedure codes for some of the newer supplemental benefits, such as food and produce.
One Medicare Advantage plan reported using a general procedure code for submitting encounter data on their benefit that provides fruit and vegetable deliveries because there was no proper procedure code for the benefit.
Other officials noted that procedure codes for some supplemental benefits do not align with how they offer the benefits, leading them to not report utilization for the benefits.
In October 2022, CMS started assessing the completeness of supplemental benefit encounter data and determining options to improve data collection for the newer benefits. However, the agency did not have a timeline for the next steps.
GAO offered two recommendations to improve encounter data collection for supplemental benefits.
First, CMS should clarify its guidance around encounter data and if submissions must include data on supplemental benefit utilization. Second, CMS should address situations where submitting encounter data on supplemental benefits is challenging for plans. The agency could create new procedure codes or a new data submission format, GAO suggested.
HHS agreed with the recommendations and said it plans to issue clarifying guidance and committed to addressing the challenges Medicare Advantage plans face.
