Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a)
Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a) (CMS-10261)
Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a)
OMB: 0938-1054
MEDICARE
PART C
REPORTING
REQUIREMENTS
PRA
Disclosure
Statement
According to the Paperwork
Reduction Act of 1995,
no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB
control number
for this
information collection is
0938-1054 and
expires on
XXXXXXXX. The time
required to complete this information collection is estimated to
average 42 hours per response, including the time to review
instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4- 26-05, and
Baltimore, Maryland 21244-1850.
Effective as of January 1, 2026
Contents
Revision History (from Contract Year 2025 to 2026) 3
Inclusions and Exclusions from Reporting 5
No Enrollment Contracts and Plans 5
Reporting Requirements Data Analysis and Limited Data Set 6
Section II. Organization Determinations & Reconsiderations 8
Subsection 1: Organization Determinations 9
Subsection 2: Disposition – All Organization Determinations 9
Subsection 3: Reconsiderations 10
Subsection 4: Disposition – All Reconsiderations 10
Section III. Employer Group Plan Sponsors 12
Section IV. Special Needs Plans (SNPs) Care Management 14
Section V. Enrollment and Disenrollment 15
Subsection 2: Disenrollment 17
Section VI. Rewards and Incentives Programs 18
Section VII. Payments to Providers 19
Subsection 5: Provider Data 20
Subsection 6: PCP/PCG-Focused Accountable Care Metrics 22
Subsection 7: Non-PCP/PCG-Focused Accountable Care Metric 22
Section VIII. Supplemental Benefit Utilization and Costs 23
Section IX. D-SNP Enrollee Advisory Committee 25
Section X. D-SNP Transmission of Admission Notifications 26
Revision History (from Contract Year 2025 to 2026)
The following list is provided as a courtesy and includes certain changes to this document made between Contract Year (CY) 2025 and CY 2026. Please compare the documents from both years for all the changes between the two CYs.
Formatting changes have been made throughout the document.
Additional information on timely submission of data has been included in the introduction. This information used to be found in the Technical Specifications.
Clarification of definitions of level of data to be reported has been added to the introduction.
Additional information on inclusions and exclusions from Reporting Sections has been included in the introduction.
Clarification has been added to the introduction about terminated contracts and contracts/plans with no enrollment.
Additional information on Data Validation has been included in the introduction.
Information has been added to the introduction on CMS Analysis of Reporting Requirements data and publication of the Limited Data Set.
The new mailbox for questions about Part C Reporting Requirements has been added to the introduction.
Duplicative information has been removed, including information duplicative of the Technical Specifications.
Information on whether each Reporting Requirement section is to be reported as a file upload or as data entry has been removed. This information is now in Technical Specifications. Note that for CY 2026, the two D-SNP Reporting Requirement sections will now be reported via file upload.
Summaries describing each Reporting Requirement section have been added.
Minor clarifications have been made to most Reporting Requirement section’s parameters table.
Information to clarify technical specifications for data elements and data upload specifications has been moved to the Technical Specifications.
Minor clarifications have been made to most Reporting Requirements sections’ data elements.
Introduction
Section 1857(e)(1) of the Social Security Act (the Act) provides broad authority for the Secretary to add terms to the contracts with Medicare Advantage Organizations (MAOs), including terms that require the sponsor to provide the Secretary with information as the Secretary may find necessary and appropriate. Pursuant to our statutory authority, we codified these information collection requirements for MAOs in regulation at 42 CFR § 422.516.
42 CFR § 422.516(a) requires each MAO to have a procedure to develop, compile, evaluate, and report to the Centers for Medicare & Medicaid Services (CMS), to its enrollees, and to the general public, at the times and in the manner that CMS requires, statistics indicating the following:
The cost of its operations.
The procedures related to and utilization of its services and items.
The availability, accessibility, and acceptability of its services.
To the extent practical, developments in the health status of its enrollees.
Information demonstrating that the MAO has a fiscally sound operation.
Other matters that CMS may require.
This document lists data elements for each reporting section, reporting timeframes, deadlines, and required levels of reporting.
Timely Submission of Data
Most reporting sections will be reported
annually. Reporting
deadlines
often
occur
in
the
subsequent
calendar
year.
Reporting deadlines and frequencies are listed in the Reporting
Requirement sections below. Data
submissions
are
due
by
11:59
p.m. Pacific
Time
on
the
date
of
the
reporting
deadline.
MAOs
must report all data based on the most current Reporting Requirements
documentation as of the reporting deadline. MAOs should be able to
support the accuracy of their data submissions based on their
understanding of the Reporting Requirements documentation. MAOs
should retain documentation supporting their Health Plan Management
System (HPMS) data submissions and resubmissions. MAOs must retain
this complete archive for the 10-year retention period required per
federal regulations and be prepared to provide the archive to CMS
upon request.
Level of Data Reported
Data elements may be reported at the Plan-level, or the individual Contract-level. Contract-level reporting indicates data should be entered at the H#, S#, R#, or E# level. Plan-level reporting indicates data should be entered at the Plan Benefit Package (PBP) level (e.g., Plan 001 for contract H#, R#, S#, or E#). Plan-level reporting is necessary to conduct appropriate oversight and monitoring of some areas. Level of reporting is listed in the Reporting Requirement sections below.
Inclusions and Exclusions from Reporting
Organization types required to report data are listed in the Reporting Requirements sections below. The following organization types are excluded from reporting all Part C Reporting Requirements:
National PACE Plans
Prescription Drug Plans (PDPs)1
Employer/Union Only Direct Contract PDPs1
LI NET Sponsor Plans
Terminations
If a contract terminates before July 1 in the following year after the CY reporting period, the contract must not report data for the respective two years – the CY reporting period, and the following year.
Example: Contract terminates June 20XX. The contract must not report CY 20XX - 1 (“CY reporting period”) or CY 20XX data (“following year”).
If a PBP (Plan) under a contract terminates at any time in the CY reporting period and the contract remains active through July 1 of the following year, the contract must report data for all PBPs, including the terminated PBP.
No Enrollment Contracts and Plans
Contracts or plans with no enrollment must not report data for any reporting section. No enrollment signifies that the contract has no enrollees for all the months within the reporting period.
Data Validation
CMS requires that sponsoring organizations (SOs) contracted to offer Medicare Part C and/or Part D benefits be subject to an independent yearly audit to validate certain data reported to CMS to determine its reliability, validity, completeness, and comparability in accordance with specifications developed by CMS.2
Reporting Sections requiring data validation are indicated in the Reporting Requirement sections below. More information about data validation can be found at https://www.cms.gov/medicare/coverage/prescription-drug-coverage-contracting/part-c-and-part-d-data-validation.
Reporting Requirements Data Analysis and Limited Data Set
CMS analyzes data submitted for accuracy and trends. In addition, certain data reported by MAOs are published annually in a Limited Data Set (LDS). More information on this LDS can be found at https://www.cms.gov/data-research/files-order/limited-data-set-lds-files/parts-c-and-d-reporting-requirements-limited-data-set.
Questions
Questions about Part C Reporting Requirements should be sent via email to PartsCDPlanReportingAndDV@cms.hhs.gov.
Reporting Sections
Section I. Grievances
MAOs must comply with grievance requirements for timely hearing and resolving of grievances as established in regulations at 42 CFR Part 422 Subpart M and further described in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
Organizations should include all 800 series plans.
Employer/Union Direct Contracts should also report this reporting section, regardless of organization type. |
1/Year, Contract Level |
Q1: 1/1-3/31 Q2: 4/1- 6/30 Q3: 7/1-9/30 Q4: 10/1-12/31
(Reporting at quarterly level) |
First Monday of February of the following year. |
Data Element ID |
Data Element Description |
A. |
Number of Total Grievances |
B. |
Number of Total Grievances in which timely notification was given |
C. |
Number of Expedited Grievances |
D. |
Number of Expedited Grievances in which timely notification was given |
E. |
Section II. Organization Determinations & Reconsiderations
42 CFR Part 422 Subpart M outlines organization determination and reconsideration requirements for MAOs, including timeframes for handling determinations, and further described in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
Organizations should include all 800 series plans.
Employer/Union Direct Contracts should also report this reporting section, regardless of organization type. |
1/Year, Contract Level |
Q1: 1/1-3/31 Q2: 4/1- 6/30 Q3: 7/1-9/30 Q4: 10/1-12/31
(Reporting at quarterly level) |
Last Monday of February of the following year.
Data Validation required. |
Subsection 1: Organization Determinations
Data Element ID |
Data Element Description |
A. |
Total Number of Organization Determinations made |
B. |
Number of Organization Determinations - Withdrawn |
C. |
Number of Organization Determinations - Dismissals |
D. |
Number of Organization Determinations requested by enrollee/representative or provider on behalf of the enrollee (Services) |
E. |
Number of Organization Determinations submitted by Enrollee/Representative (Claims) |
F. |
Number of Organization Determinations requested by Non-Contract Provider (Services) |
G. |
Number of Organization Determinations submitted by Non-Contract Provider (Claims) |
Subsection 2: Disposition – All Organization Determinations
Data Element ID |
Data Element Description |
A. |
Number of Organization Determinations – Fully Favorable (Services) Requested by enrollee/representative or provider on behalf of the enrollee |
B. |
Number of Organization Determinations – Fully Favorable (Services) Requested by Non-contract Provider |
C. |
Number of Organization Determinations – Fully Favorable (Claims) Submitted by enrollee/representative |
D. |
Number of Organization Determinations – Fully Favorable (Claims) Submitted by Non-contract Provider |
E. |
Number of Organization Determinations – Partially Favorable (Services) Requested by enrollee/representative or provider on behalf of the enrollee |
F. |
Number of Organization Determinations – Partially Favorable (Services) Requested by Non-contract Provider |
G. |
Number of Organization Determinations – Partially Favorable (Claims) Submitted by enrollee/representative. |
H. |
Number of Organization Determinations – Partially Favorable (Claims) Submitted by Non-contract Provider |
I. |
Number of Organization Determinations – Adverse (Services) Requested by enrollee/representative or provider on behalf of the enrollee |
J. |
Number of Organization Determinations – Adverse (Services) Requested by Noncontract Provider |
K. |
Number of Organization Determinations – Adverse (Claims) Submitted by enrollee/representative |
L. |
Number of Organization Determinations – Adverse (Claims) Submitted by Noncontract Provider |
Subsection 3: Reconsiderations
Data Element ID |
Data Element Description |
A. |
Total number of Reconsiderations made |
B. |
Number of Reconsiderations - Withdrawn |
C. |
Number of Reconsiderations - Dismissals |
D. |
Number of Reconsiderations requested by or on behalf of the enrollee (Services) |
E. |
Number of Reconsiderations submitted by Enrollee/Representative (Claims) |
F. |
Number of Reconsiderations requested by Non-Contract Provider (Services) |
G. |
Number of Reconsiderations submitted by Non-Contract Provider (Claims) |
Subsection 4: Disposition – All Reconsiderations
Data Element ID |
Data Element Description |
A. |
Number of Reconsiderations – Fully Favorable (Services) requested by enrollee/representative or provider on behalf of the enrollee |
B. |
Number of Reconsiderations – Fully Favorable (Services) requested by Non-contract Provider |
C. |
Number of Reconsiderations – Fully Favorable (Claims) submitted by enrollee/representative |
D. |
Number of Reconsiderations – Fully Favorable (Claims) submitted by Non-contract Provider |
E. |
Number of Reconsiderations – Partially Favorable (Services) requested by enrollee/representative or provider on behalf of the enrollee |
F. |
Number of Reconsiderations – Partially Favorable (Services) requested by Noncontract Provider |
G. |
Number of Reconsiderations – Partially Favorable (Claims) submitted by enrollee/representative |
H. |
Number of Reconsiderations – Partially Favorable (Claims) submitted by Noncontract Provider |
I. |
Number of Reconsiderations – Adverse (Services) requested by enrollee/representative or provider on behalf of the enrollee |
J. |
Number of Reconsiderations – Adverse (Services) requested by Non-contract Provider |
K |
Number of Reconsiderations – Adverse (Claims) submitted by enrollee/representative |
L. |
Number of Reconsiderations – Adverse (Claims) submitted by Non-contract Provider |
Subsection 5: Re-Openings
Data Element ID |
Data Element Description |
A. |
Total number of reopened (revised) decisions, for any reason |
B. |
Contract Number |
C. |
Case ID |
D. |
Case level (Organization Determination or Reconsideration) |
E. |
Date of original disposition |
F. |
Original disposition (Fully Favorable, Partially Favorable, or Adverse) |
G. |
Was the case processed under the expedited timeframe? (Y/N) |
H. |
Case type (Service or Claim) |
I. |
Status of treating provider (Contract, Non-contract) |
J. |
Date case was reopened |
K. |
Reason(s) for reopening (Clerical Error, Other Error, New and Material Evidence, Fraud or Similar Fault, or Other) |
L. |
Additional Information (Optional) |
M. |
Date of reopening disposition (revised decision) |
N. |
Reopening disposition (Fully Favorable; Partially Favorable, Adverse or Pending) |
Section III. Employer Group Plan Sponsors
CMS regulations (42 CFR § 422.106) stipulate specific parameters for MAOs offering employer group health plans. Additional information regarding waivers can be found in Chapter 9 of the Medicare Managed Care Manual (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c09.pdf).
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
Organizations should include all 800 series plans and any individual plans sold to employer groups.
Employer/Union Direct Contracts should also report this reporting section, regardless of organization type. |
1/Year, PBP Level |
1/1 - 12/31 (Reporting at annual level) |
First Monday of February of the following year.
Data Validation not required. |
Data Element ID |
Data Element Description |
A. |
Employer Legal Name |
B. |
Employer DBA Name |
C. |
Employer Federal Tax ID |
D |
Employer Address |
E. |
Type of Group Sponsor (employer, union, trustees of a fund) |
F. |
Organization Type (state government, local government, publicly traded organization, privately held corporation, non-profit, church group, other) |
G. |
Type of Contract (insured, ASO, other) |
H. |
Is this a calendar year plan? (Y (yes) or N (no)) |
I. |
If Element H is “N", provide non-calendar year start date. |
J. |
Section IV. Special Needs Plans (SNPs) Care Management
Title 42, Part 422, Subpart C outlines the requirements for Part C sponsors offering Special Needs Plans, including specific timeframes, health risk assessments, and models of care.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
SNP PBPs under the following types:
Only SNP Plans are required to report.
Organizations should exclude 800 series plans if they are SNPs. |
1/Year, PBP Level |
1/1-12/31 (Reporting at annual level) |
Last Monday of February in the following year.
Data Validation required. |
Data Element ID |
Data Element Description |
A. |
Number of new enrollees due for an Initial Health Risk Assessment (HRA) |
B. |
Number of enrollees eligible for an annual reassessment HRA |
C. |
Number of initial HRAs performed on new enrollees |
D. |
Number of initial HRA refusals |
E. |
Number of initial HRAs not performed because SNP is unable to reach new enrollees |
F. |
Number of annual reassessments performed on enrollees eligible for a reassessment |
G. |
Number of annual reassessment refusals |
H. |
Number of annual reassessments where SNP is unable to reach an enrollee |
Section V. Enrollment and Disenrollment
Enrollment and disenrollment requirements for Medicare Advantage (MA) and Part D plan elections are outlined at 42 CFR Part 422 Subpart B and 42 CFR Part 423 Subpart B, respectively.
For Part C reporting, MAOs offering MA-only plans (i.e., no Part D benefit) are to report enrollment, disenrollment, and reinstatement activity for these plans in this reporting section. Similarly, 1876 Cost plans are to report enrollment, disenrollment, and reinstatement activity for PBPs that do not include a Part D optional supplemental benefit. Enrollment, disenrollment, and reinstatement activity for MA prescription drug plans (MA-PDs) and 1876 Cost plan PBPs that include a Part D optional supplemental benefit must report under the appropriate section in the Part D Reporting Requirements.
For more information on these requirements, refer to the MA and Part D Enrollment and Disenrollment Guidance, available at: https://www.cms.gov/medicare/enrollment-renewal/part-d-enrollment-eligibility.
Organization Types Required to Report |
Reporting Frequency, Level |
Report Period(s) |
Data Due date(s) |
|
2/Year, Contract Level |
Period 1: 1/1-6/30 Period 2: 7/1- 12/31 (Reporting at bi-annual level) |
Last Monday of August
Last Monday of February of the following year. Data Validation is not required. |
Subsection 1: Enrollment
Subsection 2: Disenrollment
Data Element ID |
Data Element Description |
A. |
The total number of voluntary disenrollment requests received in the reporting period. Do not include disenrollments resulting from an individual’s enrollment in another plan. |
B. |
Of the total reported in Element A, the number of disenrollment requests completed at the time of initial receipt (i.e., required no additional information from enrollee or his/her authorized representative). |
C. |
Of the total reported in Element A, the number of disenrollment requests denied by the Sponsor for any reason. |
D. |
The total number of involuntary disenrollments for failure to pay plan premium in the specified time period. |
E. |
Of the total reported in Element D, the number of disenrolled individuals who submitted a timely request for reinstatement for Good Cause. |
F. |
Of the total reported in Element E, the number of favorable Good Cause determinations. |
G. |
Of the total reported in Element F, the number of individuals reinstated. |
Section VI. Rewards and Incentives Programs
42 CFR § 422.134 establishes requirements for MA sponsors offering rewards and incentives programs.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due date(s) |
Organizations should include all 800 series plans.
Employer/Union Direct Contracts should also report this reporting section, regardless of organization type. |
1/Year, Contract Level
|
1/1-12/31 (Reporting at annual level) |
Last Monday of February of the following year.
Data Validation is not required. |
Data Element ID |
Data Element Description |
A. |
Do you have a Rewards and Incentives Program(s)? (“Yes” or “No” only) |
B. |
Rewards and Incentives Program Name |
C. |
What health related services and/or activities are included in the program? |
D. |
What reward(s) may enrollees earn for participation? |
E. |
How do you calculate the value of the reward? |
F. |
How do you track enrollee participation in the program? |
G. |
How many enrollees are currently enrolled in the program? |
H. |
How many rewards have been awarded so far? |
Section VII. Payments to Providers
The Department of Health and Human Services (HHS) developed the four categories of value-based payments: fee-for-service with no link to quality (Category 1); fee-for-service with a link to quality (Category 2); alternative payment models built on fee-for-service architecture (Category 3); and population-based payment (Category 4). These groupings conform to the Health Care Payment Learning & Action Network (HCPLAN) Alternative Payment Models (APM) Framework categories. For more detailed information, please refer to the LAN APM Framework (https://hcp- lan.org/apmframework/).
CMS will collect data from MAOs about the proportion of their payments made to contracted providers based on these four categories in order to understand the extent and use of alternate payment models in the MA industry.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
|
1/Year, Contract Level |
1/1-12/31 (Reporting at annual level) |
Last Monday of February of the following year.
Data Validation not required. |
Data Element ID |
Data Element Description |
A. |
Total dollars paid to providers (in and out of network) for Medicare Advantage enrollees. |
Subsection 1: Category 1
Data Element ID |
Data Element Description |
B. |
Total dollars paid to providers through legacy payments (including fee-for-service (i.e., payments made for units of service) that are adjusted to account for neither infrastructure investments, nor provider reporting of quality data, nor provider performance on cost and quality metrics). Also includes diagnosis-related groups that are not linked to quality and value. |
Subsection 2: Category 2
Data Element ID |
Data Element Description |
C. |
Total dollars paid to providers through fee-for-service plus pay-for-reporting payments (linked to quality). |
D. |
Total dollars paid to providers through fee-for-service plus pay-for-performance payments (linked to quality) |
E. |
Dollars paid for foundational spending to improve care (linked to quality). |
F. |
Total dollars paid in Category 2. |
Subsection 3: Category 3
Data Element ID |
Data Element Description |
G. |
Total dollars paid to providers through traditional shared-savings (linked to quality) payments. |
H. |
Total dollars paid to providers through utilization-based shared-savings (linked to quality) payments. |
I. |
Total dollars paid to providers through fee-for-service-based shared-risk (linked to quality) payments. |
J. |
Total dollars paid to providers through procedure-based bundled/episode payments (linked to quality) programs. |
K. |
Total dollars paid in Category 3. |
L. |
Total Risk-based payments not linked to quality (e.g., 3N in APM definitional framework). |
Subsection 4: Category 4
Data Element ID |
Data Element Description |
M. |
Total dollars paid to providers through condition-specific, population-based payments (linked to quality). |
N. |
Total dollars paid to providers through condition-specific, bundled/episode payments (linked to quality). |
O. |
Total dollars paid to providers through population-based payments that are NOT condition-specific (linked to quality). |
P. |
Total dollars paid to providers through full or percent of premium population-based payments (linked to quality). |
Q. |
Total dollars paid to providers through integrated finance and delivery system programs (linked to quality). |
R. |
Total dollars paid in Category 4. |
S. |
Total capitation payment not linked to quality (e.g., 4N in the APM definitional framework). |
Subsection 5: Provider Data
Data Element ID |
Data Element Description |
T. |
Total number of Medicare Advantage contracted providers |
U. |
Total Medicare Advantage contracted providers paid on a fee-for-service basis with no link to quality (Category 1) |
V. |
Total Medicare Advantage contracted providers paid on a fee-for-service plus pay-for-reporting payments (linked to quality) |
W. |
Total Medicare Advantage contracted providers paid on a fee-for-service plus pay-for-performance payments (linked to quality) |
X. |
Total Medicare Advantage contracted providers paid on a fee-for-service basis with a link to quality (Category 2) |
Y. |
Total Medicare Advantage contracted providers paid based on alternative payment models built on a fee-for-service architecture (Category 3) |
Z. |
Total Medicare Advantage contracted providers paid through traditional shared savings (linked to quality) |
AA. |
Total Medicare Advantage contracted providers paid through utilization-based shared-savings (linked to quality) |
BB. |
Total Medicare Advantage contracted providers paid through fee-for-service-based shared-risk (linked to quality) |
CC. |
Total Medicare Advantage contracted providers paid through procedure-based bundled/episode payments (linked to quality) |
DD. |
Total Medicare Advantage contracted providers paid through risk-based payments not linked to quality (e.g., 3N in the APM definitional framework) |
EE. |
Total Medicare Advantage contracted providers paid through population-based payments (Category 4) |
FF. |
Total Medicare Advantage contracted providers paid through condition-specific, population-based payments (linked to quality) |
GG. |
Total Medicare Advantage contracted providers paid through condition-specific, bundled/episode payments (linked to quality) |
HH. |
Total Medicare Advantage contracted providers paid through population-based payments that are NOT condition-specific (linked to quality) |
II. |
Total Medicare Advantage contracted providers paid through full or percent of premium population-based payments (linked to quality) |
JJ. |
Total Medicare Advantage contracted providers paid through integrated finance and delivery system programs (linked to quality) |
KK. |
Total Medicare Advantage contracted providers paid based on capitation with no link to quality (e.g., Category 4N in the APM definitional framework) |
Subsection 6: PCP/PCG-Focused Accountable Care Metrics
(Metrics below apply to the number of MA plan enrollees in an accountable care arrangement. Metrics are linked to quality.)
Data Element ID |
Data Element Description |
LL. |
Total Medicare Advantage covered lives. |
MM. |
Total number of Medicare Advantage health plan enrollees attributed / aligned / assigned / empaneled to a Primary Care Provider (PCP) or Primary Care Group (PCG) participating in a TCOC Category 3 or 4 accountable care APM of six months or longer. [This does NOT include health plan enrollees attributed / aligned / assigned / empaneled to a PCP or PCG, who are paid based on capitation with no link to quality (4N)]. |
Subsection 7: Non-PCP/PCG-Focused Accountable Care Metric
(Metrics below apply to the number of MA plan enrollees in an accountable care arrangement. Metrics are linked to quality.)
Data Element ID |
Data Element Description |
NN. |
Total number of Medicare Advantage health plan enrollees attributed / aligned / assigned / empaneled to non-PCPs (i.e., specialists) participating in a TCOC Category 3 or 4 accountable care APM (e.g., shared savings with upside risk only) of six months or longer. [This does NOT include health plan enrollees attributed / aligned / assigned / empaneled to a non-PCP/PCG provider, who are paid based on capitation with no link to quality (4N)]. |
Section VIII. Supplemental Benefit Utilization and Costs
42 CFR § 422.102 provides MAO requirements for mandatory and optional supplemental benefits, and special supplemental benefits for the chronically ill (SSBCI).
Refer to the Technical Specifications for a list of the Supplemental Benefit PBP Category Codes. The Data Elements listed below must be reported for all PBP Category Codes. Any MAO that offers any of these supplemental benefits (as they noted in the PBO they submitted to CMS for the CY) is required to report this section, whether or not any beneficiaries utilized the benefit.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data due date(s) |
Organizations
should
include
all
800
series
plans. Employer/Union Direct Contracts should also report this reporting section, regardless of organization type. |
1/Year, PBP Level |
1/1-12/31 (Reporting at annual level) |
Last Monday in February of the following year
Data Validation is not required. |
Section IX. D-SNP Enrollee Advisory Committee
42 CFR § 422.107(f) establishes requirements for Enrollee Advisory Committees for any MAO offering one or more D-SNPs in a state.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
D-SNP PBPs under the following types:
|
1/Year, PBP Level |
1/1-12/31 (Reporting at annual level) |
Last Monday of February of the following year.
Data Validation is not required. |
Data Element ID |
Data Element Description |
A. |
Does the D-SNP share an enrollee advisory committee (EAC) with other D-SNP(s)? (“Yes” or “No” only) |
B. |
Provide the total number of D-SNP EAC meetings held during the measurement year. |
C. |
List the dates during the measurement year when the D-SNP EAC met. |
D. |
Were interpreter services offered for each D-SNP EAC meeting? (“Yes” or “No” only) |
E. |
Were auxiliary aids and services offered for each D-SNP EAC meeting? (“Yes” or “No” only) |
Section X. D-SNP Transmission of Admission Notifications
42 CFR § 422.107(d) establishes requirements for any D-SNP that is not a fully integrated or highly integrated D-SNP (i.e., FIDE SNP or HIDE SNP), except as specified at 42 CFR § 422.107(d)(2), to notify the State Medicaid agency or designate of hospital and skilled nursing facility admissions for at least one group of high-risk full benefit dually eligible individuals.
Organization Types Required to Report |
Report Frequency, Level |
Report Period(s) |
Data Due Date(s) |
D-SNP PBPs that are not fully integrated D-SNPs or highly integrated D-SNPs, except as specified under 42 CFR 422.107(d)(2), under the following types:
|
1/Year, PBP Level |
1/1-12/31
(Reporting at annual level) |
Last Monday of April of the following year.
Data Validation is not required. |
Data Element ID |
Data Element Description |
A. |
Provide the total number of hospital admissions and skilled nursing facility (SNF) admissions during the measurement year among the group(s) of high risk full-benefit dually eligible individuals designated in the D-SNP’s state Medicaid agency contract. |
B. |
Of the total reported in Element A, provide the total number of admission notifications that the D-SNP transmitted to the state or state designated entity during the measurement year. |
1 Denotes that these the plans are required to report the Employer Group Plan Sponsors reporting section, because this section is reported by both Part C and Part D plans.
2 See 42 CFR § 422.516(g) and § 423.514(j)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Part C Reporting Requirements |
| Subject | 2024 Data Validation |
| Author | Sky Gonzalez |
| File Modified | 0000-00-00 |
| File Created | 2025-09-21 |
© 2025 OMB.report | Privacy Policy