2026 D-SNP PPO Cost Sharing Standards for Out-of-Network Services
Relevant to: 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.
Click here to read the complete memo from CMS.
Introduction
In a recent memorandum, CMS has unveiled the final Contract Year 2026 standards for Part C Benefit Cost Sharing, focused on Dual Eligible Special Needs Plans (D-SNPs) with Preferred Provider Organizations (PPOs). These changes mandate that out-of-network cost sharing for D-SNPs align with in-network cost-sharing levels, as prescribed by the regulatory modifications in 42 CFR 422.100(o). Key highlights include new cost-sharing limits across various service categories, helping ensure more predictable and streamlined costs for beneficiaries.
Key Dates and Deadlines
- Memo release date: April 16, 2025
- Current memorandum date: April 22, 2025
- Effective date for CY 2026 standards: Contract Year 2026 (specific date not provided)
PACE Compliance
This memo is relevant to PACE programs as it outlines new regulations and standards for cost sharing that could potentially impact PACE organizations, particularly those with dual-eligible participants. While PACE organizations themselves are not structured as Dual Eligible Special Needs Plans (D-SNPs), understanding these changes is crucial for comparable scenarios within PACE settings due to shared focus on dual-eligible beneficiaries.
PACE organizations must be aware of the regulatory updates at 42 CFR 422.100(o) which affect out-of-network (OON) cost sharing, linking it to in-network cost sharing for certain services. This change could have analogous implications for PACE services that might utilize an extensive provider network.
To ensure compliance, PACE plans should consider:
– Reviewing the new regulations and the final cost sharing standards for D-SNP PPOs.
– Considering similar adjustments in their cost-sharing methodologies to align with regulatory intentions for consistency and fairness in cost-sharing for dual-eligible beneficiaries.
– Staying informed about further CMS communications for any additional adaptations that may be required.
Non-compliance with similar regulatory standards where applicable within PACE settings could lead to disruptions or compliance issues within your organization’s operational procedures.
Required Actions
1. Review the final cost-sharing standards for Dual Eligible Special Needs Plans (D-SNPs) with Preferred Provider Organizations (PPOs) for Contract Year 2026, as outlined in the memorandum.
2. Ensure that the plan benefit package submissions for D-SNP PPOs reflect enrollee cost-sharing for the specified out-of-network services in accordance with the standards and limits provided in Table 1.
3. Contact the Medicare-Medicaid Coordination Office or your CMS Account Manager via the provided email for any questions or clarifications regarding the cost-sharing standards.
FAQs
- “What are the new CY 2026 cost-sharing standards for Dual Eligible Special Needs Plans (D-SNPs) with Preferred Provider Organizations (PPOs)?”
- “How does the out-of-network cost sharing regulation at 42 CFR 422.100(o) impact D-SNP PPOs?”
- “What services are included in the final cost sharing standards for CY 2026?”
- “Are there different maximum out of pocket (MOOP) types under the new standards for 2026?”
- “Where can I find more details about these cost sharing changes for CY 2026?”
