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Feds may expand Medicare risk data access

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The Centers for Medicare & Medicaid Services (CMS) wants to get more use out of the data Medicare Advantage insurers are sending in for the Medicare Advantage risk-adjustment program.

CMS — the parent of the Center for Consumer Information & Insurance Oversight (CCIIO), the agency that oversees implementation of Patient Protection and Affordable Care Act (PPACA) commercial health insurance market programs — uses the risk-adjustment program to increase subsidies for plans that insure people who appear to be expensive to insure.

PPACA has created a new risk-adjustment for the commercial health insurance market, and CMS administration of the Medicare Advantage risk-adjustment program could be a model for how CCIIO runs the commercial health insurance risk-adjustment program. 

CMS already can use the risk-adjustment program data filings to determine the risk-adjustment factors it uses to adjust payments, conduct quality review and improvement activities, and satisfy “Medicare coverage purposes.”

CMS now wants to add several named purposes for using the insurers’ risk-adjustment program data.

One would be to “support program integrity,” a second would be to “support public health initiatives and other health care-related research,” and a third would be “for purposes permitted by other laws.”

CMS officials suggest in the preamble to the draft regulations that suggest the change that “nongovernmental external entities” could use the risk-adjustment program data for public health initiatives and health-care-related research.

CMS is seeking to balance protection of confidential beneficiary information and the proprietary interests of [Medicare Advantage] organizations with the need to effectively administer federal health care programs and to encourage research into better ways to provide health care,” officials say in the preamble. “CMS is seeking public comments on the proposed uses and release of data and how else to achieve the necessary balance. In particular, we are soliciting public comment on the extent to which a commercial purpose underlying a request for risk-adjustment data should be a factor in evaluating whether the request is for one of the purposes that permit a disclosure under this regulation.”

CMS is preparing to publish the regulations in the Federal Register May 15. Comments would be due 60 days after the official publication data.

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