[Federal Register Volume 87, Number 146 (Monday, August 1, 2022)]
[Proposed Rules]
[Pages 46918-46921]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-16463]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Chapter IV

[CMS-4203-NC]
RIN 0938-AV01


Medicare Program; Request for Information on Medicare

AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of 
Health and Human (HHS).

ACTION: Request for information.

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SUMMARY: This request for information seeks input from the public 
regarding various aspects of the Medicare Advantage program. Responses 
to this request for information may be used to inform potential future 
rulemaking or other policy development.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, by August 31, 2022.

ADDRESSES: In commenting, refer to file code CMS-4203-NC.
    Comments, including mass comment submissions, must be submitted in 
one of the following three ways (please choose only one of the ways 
listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-4203-NC, P.O. Box 8013, 
Baltimore, MD 21244-8013.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-4203-NC, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Andrew Siske (410) 786-4263.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments 
received before the close of the comment period are available for 
viewing by the public, including any personally identifiable or 
confidential business information that is included in a comment. We 
post all comments received before the close of the comment period on 
the following website as soon as possible after they have been 
received: http://www.regulations.gov. Follow the search instructions on 
that website to view public comments. CMS will not post on 
Regulations.gov public comments that make threats to individuals or 
institutions or suggest that the individual will take actions to harm 
the individual. CMS continues to encourage individuals not to submit 
duplicative comments. We will post acceptable comments from multiple 
unique commenters even if the content is identical or nearly identical 
to other comments.

I. Background

    The Vision for Medicare (https://www.cms.gov/blog/building-cms-strategic-vision-working-together-stronger-medicare) puts the person at 
the center of care and drives towards a future where people with 
Medicare receive more equitable, high quality, and whole-person care 
that is affordable and sustainable. Through this Request for 
Information (RFI), the Centers for Medicare & Medicaid Services (CMS) 
is seeking feedback on ways to strengthen Medicare Advantage (MA) in 
ways that align with the Vision for Medicare and the CMS Strategic 
Pillars (https://www.cms.gov/cms-strategic-plan). An additional goal of 
this RFI is to create more opportunities for stakeholders to engage 
with CMS, in line with the agency's Strategic Pillars that prioritize 
increased engagement with our partners and the communities we serve 
throughout the policy development and implementation process. We 
encourage input from a wide variety of voices on the questions below, 
including beneficiary advocates, plans, providers, community-based 
organizations,

[[Page 46919]]

researchers, employers and unions, and all other stakeholders.

II. Solicitation of Public Comments

A. Advance Health Equity

    CMS defines health equity as ``the attainment of the highest level 
of health for all people, where everyone has a fair and just 
opportunity to attain their optimal health regardless of race, 
ethnicity, disability, sexual orientation, gender identity, 
socioeconomic status, geography, preferred language, or other factors 
that affect access to care and health outcomes'' (https://www.cms.gov/pillar/health-equity). The CMS Framework for Health Equity (https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/framework-for-health-equity) lays out how CMS is working to advance 
health equity by designing, implementing, and operationalizing policies 
and programs that support health for all the people served by our 
programs, eliminating avoidable differences in health outcomes 
experienced by people who are disadvantaged or underserved, and 
providing the care and support that our enrollees need to thrive. We 
seek feedback regarding how we can enhance health equity for all 
enrollees through MA.
    1. What steps should CMS take to better ensure that all MA 
enrollees receive the care they need, including but not limited to the 
following:
     Enrollees from racial and ethnic minority groups.
     Enrollees who identify as lesbian, gay, bisexual, or 
another sexual orientation.
     Enrollees who identify as transgender, nonbinary, or 
another gender identity.
     Enrollees with disabilities, frailty, other serious health 
conditions, or who are nearing end of life.
     Enrollees with diverse cultural or religious beliefs and 
practices.
     Enrollees of disadvantaged socioeconomic status.
     Enrollees with limited English proficiency or other 
communication needs.
     Enrollees who live in rural or other underserved 
communities.\1\
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    \1\ CMS defines ``underserved communities'' as ``populations 
sharing a particular characteristic, as well as geographic 
communities, that have been systematically denied a full opportunity 
to participate in aspects of economic, social, and civic life.'' CMS 
derives this definition from that of the same term in Executive 
Order 13895 (United States, Executive Office of the President 
[Joseph Biden]. ``Executive Order 13985 of January 20, 2021, 
Advancing Racial Equity and Support for Underserved Communities 
Through the Federal Government,'' 86 FR 7009 (January 25, 2021), 
https://www.govinfo.gov/content/pkg/FR-2021-01-25/pdf/2021-01753.pdf.
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    2. What are examples of policies, programs, and innovations that 
can advance health equity in MA? How could CMS support the development 
and/or expansion of these efforts and what data could better inform 
this work?
    3. What are effective approaches in MA for screening, documenting, 
and furnishing health care informed by social determinants of health 
(SDOH)? \2\ Where are there gaps in health outcomes, quality, or access 
to providers and health care services due partially or fully to SDOH, 
and how might they be addressed? How could CMS, within the scope of 
applicable law, drive innovation and accountability to enable health 
care that is informed by SDOH?
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    \2\ CMS defines social determinants of health (SDOH) as ``the 
conditions in the environments where people are born, live learn, 
work, play, worship, and age that affect a wide range of health, 
functioning, and quality-of-life outcomes and risks.'' Healthy 
People 2030, U.S. Department of Health and Human Services, Office of 
Disease Prevention and Health Promotion, https://health.gov/healthypeople/priority-areas/social-determinants-health.
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    4. What have been the most successful methods for MA plans to 
ensure access to language services for enrollees in different health 
care settings? Where is improvement needed?
    5. What socioeconomic data do MA plans leverage to better 
understand their enrollees and to inform care delivery? What are the 
sources of this data? What challenges exist in obtaining, leveraging, 
or sharing such data?
    6. For MA plans and providers that partner with local community-
based organizations (for example, food banks, housing agencies, 
community action agencies, Area Agencies on Aging, Centers for 
Independent Living, other social service organizations) and/or support 
services workers (for example, community health workers or certified 
peer recovery specialists) to meet SDOH of their enrollees and/or 
patients, how have the compensation arrangements been structured? In 
the case of community-based organizations, do MA plans and providers 
tend to contract with individual organizations or networks of multiple 
organizations? Please provide examples of how MA plans and providers 
have leveraged particular MA supplemental benefits for or within such 
arrangements as well as any outcomes from these partnerships.
    7. What food- or nutrition-related supplemental benefits do MA 
plans provide today? How and at what rate do enrollees use these 
benefits, for example, for food insecurity and managing chronic 
conditions? How do these benefits improve enrollees' health? How are MA 
Special Needs Plans (SNPs) targeting enrollees who are in most need of 
these benefits? What food- or nutrition-related policy changes within 
the scope of applicable law could lead to improved health for MA 
enrollees? Please include information on clinical benefits, like 
nutrition counseling and medically-tailored meals, and benefits 
informed by social needs, such as produce prescriptions and subsidized/
free food boxes.
    8. What physical activity-related supplemental benefits do MA plans 
provide today? At what rate do enrollees use these benefits? How do 
these benefits improve enrollees' health? What physical activity-
related policy changes within the scope of applicable law could lead to 
improved health for MA enrollees?
    9. How are MA SNPs, including Dual Eligible SNPs (D-SNPs), Chronic 
Condition SNPs (C-SNPSs), and Institutional SNPs (I-SNPs), tailoring 
care for enrollees? How can CMS support strengthened efforts by SNPs to 
provide targeted, coordinated care for enrollees?
    10. How have MA plans and providers used algorithms to identify 
enrollees that need additional services or supports, such as care 
management or care coordination? Please describe prediction targets 
used by the algorithms to achieve this, such as expected future cost 
and/or utilization, whether such algorithms have been tested different 
kinds of differential treatments, impacts, or inequities, including 
racial bias, and if bias is identified, any steps taken to mitigate 
unjustified differential outcomes. For MA plans and providers that do 
test for differential outcomes in their algorithms, please provide 
information on how such tests function, how their validity is 
established, whether there is independent evaluation, and what kind of 
reporting is generated.
    11. How are MA plans currently using MA rebate dollars to advance 
health equity and to address SDOH? What data may be helpful to CMS and 
MA plans to better understand those benefits?

B. Expand Access: Coverage and Care

    CMS is committed to providing affordable quality health care for 
all people with Medicare. We seek feedback regarding how we can 
continue to strengthen beneficiary access to health services to support 
this goal in MA.
    1. What tools do beneficiaries generally, and beneficiaries within 
one or more underserved communities

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specifically, need to effectively choose between the different options 
for obtaining Medicare coverage, and among different choices for MA 
plans? How can CMS ensure access to such tools?
    2. What additional information is or could be most helpful to 
beneficiaries who are choosing whether to enroll in an MA plan or 
Traditional Medicare and Medigap?
    3. How well do MA plans' marketing efforts inform beneficiaries 
about the details of a given plan? Please provide examples of specific 
marketing elements or techniques that have either been effective or 
ineffective at helping beneficiaries navigate their options. How can 
CMS and MA plans ensure that potential enrollees understand the 
benefits a plan offers?
    4. How are MA plans providing access to behavioral health services, 
including mental health and substance use disorder services, as 
compared to physical health services, and what steps should CMS take to 
ensure enrollees have access to the covered behavioral health services 
they need?
    5. What role does telehealth play in providing access to care in 
MA? How could CMS advance equitable access to telehealth in MA? What 
policies within CMS' statutory or administrative authority could 
address access issues related to limited broadband access? How do MA 
plans evaluate the quality of a given clinician or entity's telehealth 
services?
    6. What factors do MA plans consider when determining whether to 
make changes to their networks? How could current network adequacy 
requirements be updated to further support enrollee access to primary 
care, behavioral health services, and a wide range of specialty 
services? Are there access requirements from other federal health 
insurance options, such as Medicaid or the Affordable Care Act 
Marketplaces, with which MA could better align?
    7. What factors do MA plans consider when determining which 
supplemental benefits to offer, including offering Special Supplemental 
Benefits for the Chronically Ill (SSBCIs) and benefits under CMS' MA 
Value-Based Insurance Design (VBID) Model? How are MA plans partnering 
with third parties to deliver supplemental benefits?
    8. How are enrollees made aware of supplemental benefits for which 
they qualify? How do enrollees access supplemental benefits, what 
barriers may exist for full use of those benefits, and how could access 
be improved?
    9. How do MA plans evaluate if supplemental benefits positively 
impact health outcomes for MA enrollees? What standardized data 
elements could CMS collect to better understand enrollee utilization of 
supplemental benefits and their impacts on health outcomes, social 
determinants of health, health equity, and enrollee cost sharing (in 
the MA program generally and in the MA VBID Model)?
    10. How do MA plans use utilization management techniques, such as 
prior authorization? What approaches do MA plans use to exempt certain 
clinicians or items and services from prior authorization requirements? 
What steps could CMS take to ensure utilization management does not 
adversely affect enrollees' access to medically necessary care?
    11. What data, whether currently collected by CMS or not, may be 
most meaningful for enrollees, clinicians, and/or MA plans regarding 
the applications of specific prior authorization and utilization 
management techniques? How could MA plans align on data for prior 
authorization and other utilization management techniques to reduce 
provider burden and increase efficiency?

C. Drive Innovation To Promote Person-Centered Care

    We strive to deliver better, more affordable care and improved 
health outcomes. Key to this mission are care innovations that empower 
the beneficiary to engage with their health care and other service 
providers. We seek feedback regarding how to promote innovation in 
payment and care delivery, and accountable, coordinated care responsive 
to the specific needs of each person enrolled in MA.
    1. What factors inform decisions by MA plans and providers to 
participate (or not participate) in value-based contracting within the 
MA program? How do MA plans work with providers to engage in value-
based care? What data could be helpful for CMS to collect to better 
understand value-based contracting within MA? To what extent do MA 
plans align the features of their value-based arrangements with other 
MA plans, the Medicare Shared Savings Program, Center for Medicare and 
Medicaid Innovation (CMMI) models, commercial payers, or Medicaid, and 
why?
    2. What are the experiences of providers and MA plans in value-
based contracting in MA? Are there ways that CMS may better align 
policy between MA and value-based care programs in Traditional Medicare 
(for example, Medicare Shared Savings Program Accountable Care 
Organizations) to expand value-based arrangements?
    3. What steps within CMS's statutory or administrative authority 
could CMS take to support more value-based contracting in the MA 
market? How should CMS support more MA accountable care arrangements in 
rural areas?
    4. How are providers and MA plans incorporating and measuring 
outcomes for the provision of behavioral health services in value-based 
care arrangements?
    5. What is the experience for providers who wish to simultaneously 
contract with MA plans or participate in an MA network and participate 
in an Accountable Care Organization (ACO)? How could MA plans and ACOs 
align their quality measures, data exchange requirements, attribution 
methods and other features to reduce provider burden and promote 
delivery of high-quality, equitable care?
    6. Do certain value-based arrangements serve as a ``starting 
point'' for MA plans to negotiate new value-based contracts with 
providers? If so, what are the features of these arrangements (that is, 
the quality measures used, data exchange and use, allocation of risk, 
payment structure, and risk adjustment methodology) and why do MA plans 
choose these features? How is success measured in terms of quality of 
care, equity, or reduced cost?
    7. What are the key technical and other decisions MA plans and 
providers face with respect to data exchange arrangements to inform 
population health management and care coordination efforts? How could 
CMS better support efforts of MA plans and providers to appropriately 
and effectively collect, transmit, and use appropriate data? What 
approaches could CMS pursue to advance the interoperability of health 
information across MA plans and other stakeholders? What opportunities 
are there for the recently released Trusted Exchange Framework and 
Common Agreement \3\ to support improved health information exchange 
for use cases relevant to MA plans and providers?
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    \3\ For more information, see U.S. Department of Health and 
Human Services, Office of the National Coordinator, ``Trusted 
Exchange Framework and Common Agreement (TEFCA),'' https://www.healthit.gov/topic/interoperability/trusted-exchange-framework-and-common-agreement-tefca.
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    8. How do beneficiaries use the MA Star Ratings? Do the MA Star 
Ratings quality measures accurately reflect quality of care that 
enrollees receive? If not, how could CMS improve the MA Star Ratings 
measure set to accurately reflect care and outcomes?
    9. What payment or service delivery models could CMMI test to 
further

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support MA benefit design and care delivery innovations to achieve 
higher quality, equitable, and more person-centered care? Are there 
specific innovations CMMI should consider testing to address the 
medical and non-medical needs of enrollees with serious illness through 
the full spectrum of the care continuum?
    10. Are there additional eligibility criteria or benefit design 
flexibilities that CMS could test through the MA VBID Model that would 
test how to address social determinants of health and advance health 
equity?
    11. What additional innovations could be included to further 
support care delivery and quality of care in the Hospice Benefit 
Component of the MA VBID Model? What are the advantages and 
disadvantages of receiving the hospice capitation payment as a 
standalone payment rather than as part of the bid for covering Parts A 
and B benefits?
    12. What issues specific to Employer Group Waiver Plans (EGWPs) 
should CMS consider?

D. Support Affordability and Sustainability

    We are committed to ensuring that Medicare beneficiaries have 
access to affordable, high value options. We request feedback on how we 
can improve the MA market and support effective competition.
    1. What policies could CMS explore to ensure MA payment optimally 
promotes high quality care for enrollees?
    2. What methodologies should CMS consider to ensure risk adjustment 
is accurate and sustainable? What role could risk adjustment play in 
driving health equity and addressing SDOH?
    3. As MA enrollment approaches half of the Medicare beneficiary 
population, how does that impact MA and Medicare writ large and where 
should CMS direct its focus?
    4. Are there additional considerations specific to payments to MA 
plans in Puerto Rico or other localities that CMS should consider?
    5. What are notable barriers to entry or other obstacles to 
competition within the MA market generally, in specific regions, or in 
relation to specific MA program policies? What policies might advantage 
or disadvantage MA plans of a certain plan type, size, or geography? To 
what extent does plan consolidation in the MA market affect competition 
and MA plan choices for beneficiaries? How does it affect care provided 
to enrollees? What data could CMS analyze or newly collect to better 
understand vertical integration in health care systems and the effects 
of such integration in the MA program?
    6. Are there potential improvements CMS could consider to the 
Medical Loss Ratio (MLR) methodology to ensure Medicare dollars are 
going towards beneficiary care?
    7. How could CMS further support MA plans' efforts to sustain and 
reinforce program integrity in their networks?
    8. What new approaches have MA plans employed to combat fraud, 
waste, and abuse, and how could CMS further assist and augment those 
efforts?

E. Engage Partners

    The goals of Medicare can only be achieved through partnerships and 
an ongoing dialogue between the program and enrollees and other key 
stakeholders. We request feedback regarding how we can better engage 
our valued partners and other stakeholders to continuously improve MA.
    1. What information gaps are present within the MA program for 
beneficiaries, including enrollees, and other stakeholders? What 
additional data do MA stakeholders need to better understand the MA 
program and the experience of enrollees and other stakeholders within 
MA? More generally, what steps could CMS take to increase MA 
transparency and promote engagement with the MA program?
    2. How could CMS promote collaboration amongst MA stakeholders, 
including MA enrollees, MA plans, providers, advocacy groups, trade and 
professional associations, community leaders, academics, employers and 
unions, and researchers?
    3. What steps could CMS take to enhance the voice of MA enrollees 
to inform policy development?
    4. What additional steps could CMS take to ensure that the MA 
program and MA plans are responsive to each of the communities the 
program serves?

III. Collection of Information Requirements

    Please note, this is a request for information (RFI) only. In 
accordance with the implementing regulations of the Paperwork Reduction 
Act of 1995 (PRA), specifically 5 CFR 1320.3(h)(4), this general 
solicitation is exempt from the PRA. Facts or opinions submitted in 
response to general solicitations of comments from the public, 
published in the Federal Register or other publications, regardless of 
the form or format thereof, provided that no person is required to 
supply specific information pertaining to the commenter, other than 
that necessary for self-identification, as a condition of the agency's 
full consideration, are not generally considered information 
collections and therefore not subject to the PRA.
    This RFI is issued solely for information and planning purposes; it 
does not constitute a Request for Proposal (RFP), applications, 
proposal abstracts, or quotations. This RFI does not commit the U.S. 
Government to contract for any supplies or services or make a grant 
award. Further, we are not seeking proposals through this RFI and will 
not accept unsolicited proposals. Responders are advised that the U.S. 
Government will not pay for any information or administrative costs 
incurred in response to this RFI; all costs associated with responding 
to this RFI will be solely at the interested party's expense. In 
addition, this RFI does not commit the Government to any policy 
decision and CMS will follow established methods for proposing future 
policy changes, including the MA Advance Notice and Rate Announcement 
process. We note that not responding to this RFI does not preclude 
participation in any future procurement or rulemaking, if conducted. It 
is the responsibility of the potential responders to monitor this RFI 
announcement for additional information pertaining to this request. In 
addition, we note that CMS will not respond to questions about the 
policy issues raised in this RFI.
    Chiquita Brooks-LaSure, Administrator of the Centers for Medicare & 
Medicaid Services, approved this document on July 26, 2022.

    Dated: July 27, 2022.
Xavier Becerra,
Secretary, Department of Health and Human Services.
[FR Doc. 2022-16463 Filed 7-28-22; 4:15 pm]
BILLING CODE 4120-01-P