Page 69

69

Response: Because the CMS-HCC risk adjustment model predicts total expenditures for Part A and Part B benefits, for beneficiaries with conditions such as dementia that are not directly incorporated in the 2017 CMS-HCC model, the associated costs can be predicted by comorbid conditions and demographic factors that are included in the model. To the extent that these costs are not predicted by the model, they are likely to be reflected in the frailty factors. CMS estimates frailty factors to explain additional costs not explained by diagnoses in the CMS-HCC model used to calculate risk adjusted payments for the organization in the payment year. CMS calibrates the frailty factors by regressing the residual, or unexplained, costs from the CMS-HCC risk adjustment model, onto counts of ADLs. Although total costs are included in the calibration of the 2017 CMS-HCC risk adjustment model, and the associated frailty factors help predict overall costs where diagnoses are not fully predictive, results for individual organizations may differ due to differences between the sample used for model calibration and the populations enrolled in individual plan. CMS acknowledges the concerns related to the response rates for the HOS-M for PACE participants, particularly among participants with dementia. The responses from this survey are used to determine limitations in ADLs that are accounted for in the calculation of a PACE contract’s frailty score. We collect survey data in a consistent manner for all PACE organizations, as this helps to ensure equitable frailty results for payment. In addition, ADL data are collected to calculate frailty scores in the same manner that these data are collected and used to calculate frailty factors for model calibration (i.e., limitations in activities of daily living collected from self-reported surveys). Permitting variation in how the survey is administered for participants with specific conditions may disproportionately affect frailty scores for certain organizations, depending on what proportion of an organization’s participants have that condition and which organizations provide the assistance. There are existing proxy allowances in the survey administration protocol. For the HOS-M survey, a proxy response is at the discretion of the PACE participant, but PACE staff may inform the family member or caregiver of their right to request a proxy if participants with dementia need assistance completing the survey. Section M. MA Coding Pattern Difference Adjustment Comment: Several commenters supported CMS’ proposed 5.9 percent MA coding pattern adjustment factor for CY 2026. Response: CMS appreciates the support of the commenters. CMS is finalizing the proposed MA coding pattern adjustment factor of 5.9 percent for CY 2026. Comment: Several commenters opposed CMS’ proposed 5.9 percent MA coding pattern adjustment factor for CY 2026 and provided alternative recommendations to the statutory minimum adjustment factor of 5.9 percent, as summarized below: