AHA Comments on CMS Medicare Parts C and D Reporting Requirements

May 5, 2026

The Honorable Mehmet Oz, M.D.
Administrator
Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore, MD 21244

Re: CMS-10185 Medicare Part C and D Reporting Requirements

Dear Administrator Oz:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS’) revised Medicare Part C and D Reporting Requirements.

As CMS has recognized, these reporting data play a critical role in the agency’s ability to conduct effective oversight, monitoring and compliance activities across the Medicare Advantage (MA) program. Robust, sufficiently granular reporting enables CMS to identify outliers, detect emerging patterns and evaluate whether MA Organizations (MAOs) are adhering to program requirements, particularly where beneficiary protections and access to medically necessary care are at stake. The importance of strong MAO reporting has become even more pronounced in light of recent program changes, including CMS’ decision in the contract year (CY) 2027 MA final rule to simplify and refocus the Star Ratings measure set by removing certain measures, including removing the appeals and complaints measures. Thus, the AHA strongly supports CMS’ continued collection of meaningful MAO reporting data, which are essential to effective oversight and enforcement of MA standards.

Moreover, the financial incentives tied to the Star Ratings play an important role in shaping plan behavior. Removing these measures reduces the direct incentive for MAOs to invest upfront resources in identifying and addressing problems related to coverage decisions, appeals and member complaints before they escalate. As a result, CMS must rely on its direct oversight and enforcement tools, including robust, granular reporting data, to identify emerging patterns of problematic MAO behavior that may affect access to medically necessary care or undermine beneficiary protections.

The AHA recommends that CMS consider refinements to its MA reporting requirements to strengthen oversight, monitoring and health plan accountability across key areas of plan performance. In particular, CMS should consider modest enhancements to reporting on organization determinations and reconsiderations and grievances (such as additional stratification or standardized categories) that would make the data more actionable for identifying patterns and potential systemic concerns. CMS also should consider whether expanded transparency, including appropriate public reporting, would further support CMS’ oversight efforts and help beneficiaries, providers and policymakers better understand MAO practices and performance.

Organization Determinations and Reconsiderations

CMS’ reporting on organization determinations and reconsiderations is particularly critical to understanding how MAOs make, implement and revisit coverage decisions. CMS currently collects contract-level data on organization determinations and reconsiderations, including total volumes, requestor type, disposition and reopenings. This section is one of the most important tools available to CMS for understanding how MAOs make coverage decisions and how those decisions change when challenged. Because these data capture both the initial coverage decision and whether that decision is later sustained, modified or reversed through reconsideration and reopening, they give CMS one of its clearest views into whether MAOs are creating inappropriate barriers to medically necessary care.

The AHA encourages CMS to refine this section so the data are more actionable for oversight and enforcement. In particular, we recommend considering modest additional stratification for the agency to better distinguish among key types of decisions and appeals pathways. For example, we recommend that CMS consider whether reporting can better differentiate expedited and standard cases, and better identify the types of services or requests most frequently associated with adverse outcomes and reconsiderations. These refinements would improve CMS’ ability to identify patterns that may signal inappropriate barriers to medically necessary care, noncompliance with MA coverage rules or systemic problems in how MAOs process coverage requests.

Grievances

While organization determination and reconsideration data illuminate how coverage decisions are made and appealed, grievance reporting provides a complementary perspective on how beneficiaries experience plan operations more broadly. CMS continues to collect contract-level grievance data, including the total number of grievances, timely notifications, expedited grievances and dismissals. Grievance data can provide an important signal of beneficiary experience and plan performance, particularly when patterns emerge across contracts or over time. 

The AHA recommends that CMS consider strengthening this section by requiring a limited number of standardized grievance categories so grievances can be grouped into meaningful issue types, such as access delays, coverage and authorization problems, provider network issues, customer service concerns or payment-related problems. CMS also should consider whether grievance data can be structured to better support trend analysis and identification of recurring problems within or across contracts. Even modest refinement in this area would materially improve the utility of the data for monitoring and enforcement.

Transparency and Accountability

Beyond CMS’ internal use of these reporting data for monitoring, compliance and enforcement, we urge the agency to consider how greater transparency can reinforce accountability across all reporting domains discussed above. CMS’ reporting requirements note that certain reported data are published annually in a limited data set. Greater transparency can complement CMS’ own oversight efforts and help beneficiaries, providers and policymakers better understand MAO performance.

We thank you for the opportunity to comment. We look forward to continued engagement with CMS on strengthening MA oversight and accountability. Please contact me if you have any questions, or feel free to have a member of your team contact Noah Isserman, AHA’s director of health insurance and coverage policy, at nisserman@aha.org.

Sincerely,
/s/
Ashley Thompson
Senior Vice President
Public Policy Analysis and Development