Medicare Advantage: Questionable Use of Health Risk Assessments Among Dual-Eligible Special Needs Plans

In Medicare Advantage (MA), Dual Eligible Special Needs Plans (D-SNPs) are designed to better manage and coordinate care for high-need patients who are dually eligible for both Medicare and Medicaid. For most health conditions, D-SNPs receive potentially higher MA payments than most other types of plans to care for their high-need patients. In addition, D-SNPs must fulfill certain care coordination requirements that do not apply to non-SNP MA plans, including the requirement to maintain procedures for care coordination activities following enrollee health risk assessments (HRAs). Despite these higher payments and additional requirements, OIG and other researchers have raised concerns about MA plans' use of HRAs to generate payments without also coordinating followup care, as required for all D-SNPs. This evaluation will determine the extent to which D-SNPs received 2025 risk-adjusted payments for diagnoses reported only on HRAs (or added to HRAs by chart reviews) and no other records of service in the MA or Medicaid data. We also will assess the extent to which select plans complied with certain care coordination requirements.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
June 2025	CMS	Medicare Advantage: Questionable Use of Health Risk Assessments Among Dual-Eligible Special Needs Plans	Office of Evaluation and Inspections	OEI-03-25-00210	2027