Data on Medicare Advantage Supplemental Benefits Limited for CMS

A report investigates the information the federal agency has on enrollees' utilization of Medicare Advantage (MA) supplemental benefits.

While almost all MA plans offer supplemental benefits, data on their usage is lacking for CMS, according to a report from the Government Accountability Office (GAO).

The research analyzed plan benefit data for 3,893 MA plans in the 50 states and District of Columbia, reviewed CMS regulations and guidance, and interviewed officials from CMS and six MA plans to better understand how much information on beneficiaries' utilization was available in 2022.

GAO found that all but one plan offered at least one supplemental benefit not covered under traditional Medicare, with vision and hearing being the most common at 98% and 94%, respectively.

The report states that MA plans could offer benefits to reduce avoidable healthcare use beginning 2019 and could offer benefits to improve or maintain the health of chronically ill enrollees beginning 2020. Only one-third of plans offered at least one of the new benefits in 2022—most commonly in-home support services (17%) and food and produce (15%).

MA plans are required to submit data of utilization of these services, known as encounter data, to CMS, but GAO found that information to be limited for two reasons.

Firstly, CMS guidance on encounter data does not specifically mention supplemental benefits, although CMS officials told GAO that the guidance does not differentiate between supplemental and traditional Medicare benefits. However, three officials from MA organizations told the researchers that encounter data for supplemental benefits is not required and that they do not submit it.

Secondly, collecting and submitting encounter data for certain supplemental benefits can be a challenge, according to officials from CMS and two MA organizations. Newer supplemental benefits like food and produce have no procedure code, for example.

"As of October 2022, CMS was in the early stages of assessing the completeness of the encounter data for supplemental benefits and identifying options for collecting enrollee utilization data for the newer benefits but did not have a workplan or timeline for next steps," GAO stated.

"More complete information on enrollees' use of supplemental benefits would put CMS in a stronger position to ensure the benefits effectively support the health and social needs of enrollees."

The report recommended two steps for CMS: clarifying guidance on which encounter data submissions require data on supplemental benefits and addressing circumstances where submitting encounter data for benefits is challenging. HHS concurred with GAO's recommendations.