Encounter Data Enhancement Act

“(j) Inclusion of certain information in encounter data

“(1) In general—In the case of any encounter data submitted by a Medicare Advantage plan with respect to an item or service furnished to an individual under such plan during a plan year beginning on or after January 1, 2026, the Secretary shall require that such data include—

“(A) the type of payment from the plan to the provider, such as, but not limited to capitation, value-based, or fee-for-service;

“(B) the allowed amount for such item or service;

“(C) the amount of cost sharing (including deductibles, copayments, and coinsurance) imposed for such item or service;

“(D) an indicator identifying encounter records including the provision of an at-home health risk assessment by a specified assessment entity;

“(E) an indicator identifying encounter records including the provision of an at-home health risk assessment by an assessment entity not described in subparagraph (D);

“(F) an indicator identifying encounter records including the provision of an at-home health risk assessment by an entity not described in subparagraph (D) or (E);

“(G) an indicator identifying encounter records including the provision of a health risk assessment outside of the home by any entity;

“(H) an indicator of whether the item or service was provided in-network for the plan; and

“(I) the standard unique health identifier (described in section 1173(b)) of the ordering provider, in the case of data submitted with respect to—

“(i) durable medical equipment, prosthetics, orthotics, and supplies;

“(ii) laboratory tests;

“(iii) imaging services;

“(iv) home health services; and

“(v) other items or services as determined by the Secretary.

“(2) Definitions—For purposes of this subsection:

“(A) Assessment entity—The term assessment entity means an entity with a focus on furnishing in-home health risk assessments, as specified by the Secretary.

“(B) Specified assessment entity—The term specified assessment entity means, with respect to an MA organization and a plan year, an assessment entity with respect to which such organization (or any person with an ownership or control interest (as defined in section 1124(a)(3)) in such organization) is a person with an ownership or control interest (as so defined).”