2026 Advance Notice: CMS Part D Risk Scores for RxHCC Model
Relevant to: PDP, PACE, Part D
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Introduction
The Centers for Medicare & Medicaid Services (CMS) has published the Advance Notice for Calendar Year 2026, focusing on updates to the RxHCC risk adjustment models. This instrumental document guides Medicare Advantage and Part D plans with crucial updates on proposed risk scores now available via the HPMS portal. These scores, essential for plan operations, reflect diagnoses from prior years, ensuring calculated accuracy and alignment with CMS guidelines.
Key Dates and Deadlines
- Date of Memo: January 10, 2025
- Publication of the 2026 Advance Notice: January 10, 2025
- Proposed PY 2026 Part D Model Risk Scores: Present in the memo for access
- Risk Scores calculated for PY 2025 and models for CY 2026 are discussed
PACE Compliance
This memo is relevant to PACE organizations due to the proposed changes in the RxHCC risk adjustment models as discussed in the 2026 Advance Notice. For PACE organizations, CMS has calculated the Part D risk scores using the risk adjustment model currently in place for Payment Year (PY) 2025 as well as the proposed and alternate RxHCC models for PY 2026. These risk scores are computed using diagnoses from RAPS, encounter data, and Fee-for-Service (FFS) claims that are filtered with specialty-based filtering logic.
PACE organizations must review these proposed risk scores as they may impact future payment rates and risk adjustment processes. It is important for PACE organizations to understand how risk scores are being calculated and the methodology behind the RxHCC models, ensuring that diagnosis submissions are accurate and complete to achieve appropriate risk score outcomes.
Organizations should prepare for compliance with any new requirements that may be finalized in the CY 2026 Advance Notice. Stakeholders are encouraged to submit comments on the proposals to ensure all concerns are considered. Technical questions should be directed to the specified email with the appropriate subject line for clarity.
Required Actions
1. Review the Part D plan-level risk scores posted on HPMS under the heading “Proposed Risk Scores.” Select “Proposed PY 2026 Part D Model Risk Scores” and enter the Contract ID for information related to your specific contract.
2. For Non-PACE Organizations: Consider the provided Part D risk scores, which include calculations using the 2025 RxHCC model and the proposed models in the CY 2026 Advance Notice, using diagnoses from encounter data and FFS claims filtered based on HCPCS codes.
3. If applicable, submit any comments on the proposals in the CY 2026 Advance Notice through www.regulations.gov by entering the docket number “CMS-2024-0360” and following the submission instructions. For further technical questions regarding the risk scores, contact riskadjustmentpolicy@cms.hhs.gov with “2026 Advance Notice Part D Risk Scores” in the subject line.
FAQs
- “What are Part D risk scores and how are they calculated for 2026?”
- “Where can I find the proposed Part D risk scores for 2026?”
- “How are diagnoses used in calculating the RxHCC models for Part D risk scores?”
- “What should PACE organizations know about the 2026 proposed risk scores?”
- “How can I submit comments on the 2026 Advance Notice proposals?”