NCQA Comments on Risk Adjusting Medicare Advantage Payment for Duals

NCQA supports CMS’ plan to pay Medicare Advantage plans more for the higher cost of serving enrollees eligible for both Medicare and Medicaid.

November 25, 2015

Cheri Rice, Director
Medicare Plan Payment Group
Center for Medicare & Medicare Services
7500 Security Blvd.
Baltimore, MD

Thank you for the opportunity to comment on your proposed changes to the CMS-HCC risk adjustment model for 2017. The National Committee for Quality Assurance (NCQA) strongly supports this effort to better account for the higher costs in caring for beneficiaries who are dually eligible for both Medicare and Medicaid. This is vital for all plans, especially those in the Financial Alignment Initiative that are integrating both Medicare and Medicaid coverage and payment.

Your data-driven approach in proposing payment adjustments based on assessments of the average predicted costs for different subsets of dual eligibles makes sense. Payments that accurately reflect actual care costs for specific categories of lower socioeconomic enrollees will help more plans address related disparities and achieve the high quality care all Medicare enrollees deserve.

Risk adjustment to payments, rather than to performance measures, is the best way to address disparities in care and related average differences in the Medicare Advantage Star Ratings. It is much more constructive thank risk adjustment to Star Ratings measures, which would mask disparities without addressing them and lock in lower expectations for those who most need improved quality.

This distinction is critical, as our research shows that some plans do achieve high quality despite having large numbers of lower socioeconomic enrollees. As we noted in our comments on the proposed 2016 Call Letter, some plans with high dual enrollment rates perform well above average on measures for which plans with high dual enrollment on average perform below average. It is imperative that plans have the resources they need to address disparities, rather than dismiss them as something that cannot be helped by risk adjustment to measures themselves.

Thank you for the opportunity to comment. Please contact Paul Cotton, Director of Federal Affairs, at 202 955 5162 or if you have any questions.


Margaret O’Kane,

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