HR-9392-119
Forwarded by Subcommittee to Full Committee by Voice Vote.
Sponsored by Diana DeGette (D-CO)
What it does
This bill would require Medicare Advantage plans to include additional information in the encounter data they submit to the federal government for items and services provided starting in plan year 2027. This includes the allowed payment amount, patient cost-sharing amounts, and flags indicating whether a patient received an in-home health risk assessment, distinguishing whether that assessment was done by an entity affiliated with the plan's own parent organization or by an unaffiliated entity.
Who benefits
Federal regulators (CMS) and researchers analyzing Medicare Advantage spending patterns; policymakers seeking to detect upcoding or risk-score inflation tied to in-home assessments; potentially taxpayers if the data leads to reduced improper payments; unaffiliated home assessment companies competing against plan-owned assessment entities, who could benefit from increased scrutiny of self-dealing arrangements.
Who is hurt
Medicare Advantage organizations and their affiliated home health risk assessment subsidiaries, which would face new data reporting burdens and increased visibility into vertically integrated business practices; plans may incur administrative and compliance costs to build new reporting systems, which could be passed through to enrollees or absorbed as reduced margins.
Supporters argue
Supporters argue that Medicare Advantage plans' use of in-home health risk assessments has been linked by federal watchdogs, including HHS Office of Inspector General reports, to inflated risk scores and billions of dollars in additional federal payments, particularly when plans use their own affiliated assessment companies. They contend that requiring plans to flag whether an assessment came from an affiliated entity gives CMS and Congress the data needed to identify and address potential self-dealing without banning the practice outright.
Opponents argue
Opponents argue that the bill imposes new administrative reporting burdens on Medicare Advantage plans without directly addressing any underlying payment or coverage problem, since it only requires disclosure rather than changing reimbursement rules. They contend that expanded data requirements could raise compliance costs that plans pass on to enrollees through higher premiums or reduced benefits, and that the bill's narrow focus on encounter data may generate limited practical benefit relative to its administrative cost.
Constitutional context
Congress has broad authority under the Spending Clause to set conditions on Medicare Advantage plans that participate in a federally funded program, and this bill's reporting mandate falls squarely within that established authority rather than raising Commerce Clause or coercion concerns since it applies to voluntary program participants rather than compelling private conduct.
Checks and balances
Congress directs the Secretary of Health and Human Services to require specific new data fields in Medicare Advantage encounter data, with the agency retaining discretion to define key terms like "assessment entity," subject to standard administrative rulemaking review.
Historical precedent
Congress has previously required expanded Medicare Advantage encounter data reporting, including risk-adjustment data submission requirements enacted in prior years, though this specific disclosure of affiliated home assessment entities is a novel addition.