CMS Releases Beneficiary-Level File for 2026 Part D Bids Development
Relevant to: PDP, PACE, Part D
Each week, we scan the latest CMS memos to find the most important ones that apply for PACE programs. Below is a summary of what you need to know.
Disclaimer: The content provided on this site is a summary for informational purposes only, and Grane PBM, Inc. assumes no liability for any errors or omissions in the site’s content. The information does not constitute legal or regulatory advice or replace the original CMS memo. Readers are advised to consult the CMS memo in its entirety and to verify information independently before making any decisions based on this information.
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Introduction
CMS has distributed a beneficiary-level file to Medicare Advantage-Prescription Drug plans, 1876 Cost Plans, PACE organizations, and standalone PDPs, essential for 2026 Part D bid development. This data is critical for actuaries, including contract-specific risk scores and other key metrics. Additionally, contract-PBP level risk scores for the payment year model are available on HPMS, providing comprehensive support for upcoming bids. Plans are encouraged to review the information to ensure compliance and proper bid formulation.
Key Dates and Deadlines
- Date of Memo: April 10, 2025
- Publication Date of CY 2020 Rate Announcement: April 1, 2019
- Publication Date of CY 2023 Rate Announcement: April 4, 2022
- Publication Date of CY 2026 Rate Announcement: April 7, 2025
- Deadline for Diagnosis Data Submission for Risk Score Estimates: January 31, 2025
- Deadline for Enrollment and Disenrollment Adjustments: January 2025
- Deadline for LTI Status Adjustment: February 7, 2025
PACE Compliance
This memo is relevant to PACE programs due to its details on the beneficiary-level files for 2026 Part D bids, which include aspects pertinent to PACE organizations. PACE organizations are expected to utilize beneficiary-level files provided by CMS to assist their actuaries in developing Part D bids for 2026. The memo explains that currently, the estimated risk scores for PACE organizations have been calculated using both the 2020 RxHCC model and the new 2026 RxHCC model, with differing calibration years (2018/2019 for the 2026 model). PACE organizations must ensure they apply the appropriate calibration and normalization factors when using these scores in bid preparations.
Plans must consider the following key points:
– The Part D risk score file layouts specific to PACE organizations are detailed separately within the memo.
– The 2026 risk scores need to be appropriately normalized using the specified factors for PACE organizations, which for the 2026 RxHCC model is a normalization factor of 1.202.
– PACE organizations need to incorporate all provided risk score data, such as those calculated using RAPS, EDS, and FFS claims, into their bid pricing evaluations.
Failure to comply with these requirements can impact the bid submission, potentially leading to inaccuracies or non-compliance issues in the final bids submitted for CMS review.
Required Actions
1. Confirm receipt of the beneficiary-level file sent by CMS for developing 2026 Part D bids, ensuring you can access the file using the provided technical specifications.
2. Review the file, paying particular attention to estimated payment year risk scores and ensure your plan’s actuaries incorporate these scores into the bid process for 2026.
3. Fetch the contract-level risk scores for the payment year model on HPMS and analyze them to align your strategy and planning for submissions.
FAQs
- “What is the purpose of the beneficiary-level file sent by CMS for 2026 Part D bids?”
- “How should actuaries use the CMS beneficiary-level file for developing 2026 Part D bids?”
- “What are the details of the Part D file name structure provided by CMS?”
- “How are the 2024 Part D risk scores calculated and what models are used?”
- “What should plans do if they have questions regarding the file retrieval or content?”
