Ensuring appropriate oversight of Medicare Advantage plans

(a) MAO compliance scoring and accountability program Section 1853 of the Social Security Act (42 U.S.C. 1395w–23) is amended by adding at the end the following new subsection: (p) Compliance scoring and enforcement (1) Payment reductions for MAOs in noncompliance with certain MA program requirements (A) In general In the case of a Medicare Advantage organization with a contract under this part that the Secretary determines, in accordance with this subsection, to be within a compliance tier specified in subparagraph (B) for a performance period with respect to a plan year beginning on or after January 1, 2028, the Secretary shall reduce the total of the monthly payments made for the plan year under section 1853(a)(1) to the Medicare Advantage organization with respect to each Medicare Advantage plan offered by such organization by the applicable percent specified under subparagraph (B) with respect to the compliance tier. (B) Applicable percent specified For purposes of subparagraph (A), the applicable percent specified under this subparagraph is as follows: (i) With respect to the compliance tier described in paragraph (5)(B), 1.0 percent. (ii) With respect to the compliance tier described in paragraph (5)(C), 1.5 percent. (iii) With respect to the compliance tier described in paragraph (5)(D), 2.0 percent. (C) Performance period For purposes of this subsection, the Secretary shall establish a performance period (or periods) for each plan year beginning on or after January 1, 2028. Such performance period (or periods) shall begin and end prior to the beginning of the plan year and be as close as possible to such plan year. In this subsection, such performance period (or periods) for a plan year shall be referred to as the performance period with respect to the plan year. (2) Establishment of compliance scoring and accountability program For purposes of this subsection, the Secretary shall establish a Medicare Advantage organization compliance scoring and accountability program (referred to under this subsection as the MAO Compliance Program) under which, for each Medicare Advantage organization with a contract under this part and each performance period with respect to a plan year beginning on or after January 1, 2028, the Secretary— (A) using the method established under paragraph (3)(A), shall assess the extent to which the Medicare Advantage organization is in compliance with requirements under this part applicable to each compliance category specified under paragraph (3)(B); (B) based on such assessments for each such compliance category, shall assign a total compliance score to the Medicare Advantage organization, in accordance with paragraph (4); and (C) based on such total compliance score, shall assign the Medicare Advantage organization to a compliance tier described in paragraph (5). (3) Assessment method (A) In general Under the MAO Compliance Program, the Secretary shall establish through notice and comment rulemaking a method to assess, at the plan level, the extent to which each Medicare Advantage organization offering a Medicare Advantage plan is in compliance with requirements under this part applicable to each compliance category specified in subparagraph (B). Such method shall include the use of audit mechanisms, reporting requirements, performance measures established or identified by the Secretary (such as applicable measures under the MA Program Compliance and Coverage Protection Domain described in section 1853(o)(8)), and such other methods as specified by the Secretary. (B) Compliance categories (i) In general Subject to clause (ii), under the MAO Compliance Program, each of the following shall be a compliance category: (I) Compliance with timely and real-time specified authorization decision-making requirements, including compliance with section 1852(d)(7) and paragraphs (1)(C), (1)(D), and (3)(B)(iii)(II) of section 1852(g). (II) Compliance with coverage criteria standards, including the requirements under section 1852(g)(7) and section 1852(a)(2)(D). (III) Compliance with prompt payment requirements, including compliance with section 1857(f). (IV) Compliance with restrictions regarding improper retroactive denials and downgrades, including compliance with section 1852(g)(6) and section 1857(e)(7). (V) Compliance with marketing, enrollment, and beneficiary communication requirements, including subpart V of part 422 of title 42, Code of Federal Regulations, or any successor to such regulations. (VI) Compliance with other requirements under this part, including section 1852(g)(1)(E) and such other requirements as specified by the Secretary. (ii) Updates The Secretary may, through notice and comment rulemaking, revise the compliance categories described in clause (i), including by specifying additional categories, removing categories, and otherwise updating the requirements that are included in any of such compliance categories. (4) Scoring methodology Under the MAO Compliance Program, the Secretary shall, through notice and comment rulemaking, establish a methodology to assign a total compliance score (using a scoring scale of 0 to 100) to each Medicare Advantage organization for the performance period with respect to a plan year. Such total compliance score shall be based on the assessment under paragraph (3) of plan-level compliance with respect to each compliance category described in subparagraph (B) of such paragraph, with each such category receiving equal weight (and, in the case of a Medicare Advantage organization offering more than one plan during the performance period, with each such assessment weighted by the number of individuals enrolled under such plan during such period). (5) Compliance tiers For each plan year beginning on or after January 1, 2028, the Secretary shall, based on the total compliance score assigned pursuant to paragraph (4) to a Medicare Advantage organization for the performance period with respect to such year, assign such Medicare Advantage organization to one of the following compliance tiers, as follows: (A) Compliance tier one, consisting of Medicare Advantage organizations receiving a total score for the performance period of at least 90. (B) Compliance tier two, consisting of Medicare Advantage organizations receiving a total score for the performance period of at least 75 but not more than 89. (C) Compliance tier three, consisting of Medicare Advantage organizations receiving a total score for the performance period of at least 60 but not more than 74. (D) Compliance tier four, consisting of Medicare Advantage organizations receiving a total score for the performance period of less than 60. (6) Review The Secretary shall establish a process under which a Medicare Advantage organization may seek a review of the total compliance score assigned to the organization pursuant to paragraph (4) for a performance period. (7) Public disclosures (A) In general For each plan year beginning on or after January 1, 2028, the Secretary shall make available on a public website of the Centers for Medicare & Medicaid Services and in an easily understandable format, information regarding the assessments under the MAO Compliance Program of compliance during the performance period with respect to the plan year by Medicare Advantage organizations, on the plan level, with requirements applicable to each compliance category specified in paragraph (3)(B). Such information shall include the total compliance score received by each Medicare Advantage organization pursuant to paragraph (4) for the performance period. (B) Opportunity to review and submit corrections The Secretary shall provide for an opportunity for a Medicare Advantage organization to review and submit corrections for the information to be made available under subparagraph (A) with respect to such organization prior to such information being made public.. (b) Expanding the MA star ratings program To include an MA program compliance and coverage protection domain (1) Data collection Section 1852(e)(3) of the Social Security Act (42 U.S.C. 1395w–22(e)(3)) is amended— (A) in subparagraph (A)(i), in the first sentence by inserting, including, for plan years beginning on or after January 1, 2028, with respect to measures under the MA Program Compliance and Coverage Protection Domain described in section 1853(o)(8) after other indices of quality; and (B) in subparagraph (B)(i), by inserting, and other than the types of data authorized under subparagraph (C) of section 1853(o)(8) for purposes of the MA Program Compliance and Coverage Protection Domain described in such section after as of November 1, 2003. (2) Addition of MA program compliance and coverage protection domain to MA star ratings system Section 1853(o) of the Social Security Act (42 U.S.C. 1395w–23(o)) is amended by adding at the end the following new paragraph: (8) MA program compliance and coverage protection domain (A) In general For plan years beginning on or after January 1, 2028, in addition to any other domain under the 5-star rating system under paragraph (4)(A) used for determining star ratings of Medicare Advantage plans, the Secretary shall include under such system an MA Program Compliance and Coverage Protection Domain. (B) Measures Such domain shall include measures to assess compliance of each Medicare Advantage plan with each of the compliance categories specified in section 1853(p)(3)(B). (C) Data For purposes of determining star ratings with respect to measures under the MA Program Compliance and Coverage Protection Domain, in addition to sources of data otherwise collected under section 1852(e)(3), the Secretary may use data collected pursuant to audits, complaint tracking systems, appeals data, determinations made by independent review entities, and such other sources as specified by the Secretary. (D) Application of weighting In applying section 422.166(e) of title 42, Code of Federal Regulations, or a successor regulation, with respect to the MA Program Compliance and Coverage Protection Domain, the Secretary shall assign a weight to measures included under such domain that is greater than the weight assigned to measures included under any other domain..