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pdfMedicare PartMEDICARE
PART C
Reporting RequirementsREPORTING
REQUIREMENTS
Effective January 1, 20265
Prepared by:
Centers for Medicare & Medicaid Services
Center for Medicare Drug Benefit and C&D Data Group
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 January 31, 2028XXXXXXXX. 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, and 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
Table of Contents
Contents
Revision History (from Contract Year 2025 to 2026) ...................................................................... 5
Introduction................................................................................................................................................ 6
Timely Submission of Data ....................................................................................................................... 7
Level of Data Reported ............................................................................................................................. 7
Inclusions and Exclusions from Reporting................................................................................................ 7
Terminations .......................................................................................................................................... 8
No Enrollment Contracts and Plans ...................................................................................................... 8
Data Validation .......................................................................................................................................... 8
Reporting Requirements Data Analysis and Limited Data Set ................................................................ 8
Questions .................................................................................................................................................. 8
Reporting Sections ................................................................................................................................ 10
Section I.
Grievances .......................................................................................................................... 10
Section II.
Organization Determinations & Reconsiderations ......................................................... 13
Subsection 1: Organization Determinations........................................................................................ 14
Subsection 2: Disposition – All Organization Determinations............................................................. 14
Subsection 3: Reconsiderations .......................................................................................................... 15
Subsection 4: Disposition – All Reconsiderations............................................................................... 15
Subsection 5: Re-Openings................................................................................................................. 16
Section III.
Employer Group Plan Sponsors...................................................................................... 18
Section IV.
Special Needs Plans (SNPs) Care Management........................................................... 20
Section V.
Enrollment and Disenrollment......................................................................................... 23
Subsection 1: Enrollment..................................................................................................................... 25
Subsection 2: Disenrollment................................................................................................................ 26
Section VI.
Rewards and Incentives Programs................................................................................. 27
Section VII.
Payments to Providers.................................................................................................... 29
Subsection 1: Category 1 .................................................................................................................... 30
Subsection 2: Category 2 .................................................................................................................... 30
Subsection 3: Category 3 .................................................................................................................... 31
Subsection 4: Category 4 .................................................................................................................... 31
Subsection 5: Provider Data................................................................................................................ 32
Subsection 6: PCP/PCG-Focused Accountable Care Metrics ........................................................... 33
Subsection 7: Non-PCP/PCG-Focused Accountable Care Metric ..................................................... 33
Section VIII.
Supplemental Benefit Utilization and Costs .................................................................. 34
Section IX.
D-SNP Enrollee Advisory Committee .............................................................................. 43
Section X.
D-SNP Transmission of Admission Notifications............................................................. 44
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 changes between the two CYs.
1. Formatting changes have been made throughout the document.
2. Additional information on timely submission of data has been included in the introduction.
This information used to be found in the Technical Specifications.
3. Clarification of definitions of level of data to be reported has been added to the
introduction.
4. Additional information on inclusions and exclusions from Reporting Sections has been
included in the introduction.
5. Clarification has been added to the introduction about terminated contracts and
contracts/plans with no enrollment.
6. Additional information on Data Validation has been included in the introduction.
7. Information has been added to the introduction on CMS Analysis of Reporting
Requirements data and publication of the Limited Data Set.
8. The new mailbox for questions about Part C Reporting Requirements has been added to
the introduction.
9. Duplicative information has been removed, including information duplicative of the
Technical Specifications.
10. 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.
11. Summaries describing each Reporting Requirement section have been added.
12. Minor clarifications have made to most Reporting Requirement section’s parameters
table.
13. Information to clarify technical specifications for data elements and data upload
specifications has been moved to the Technical Specifications.
14. Minor clarifications have been made to most Reporting Requirements sections’ data
elements.
Page 5 of 44
Formatted: Space After: 12 pt
Background and 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:
1)
2)
3)
4)
5)
6)
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 MA organization has a fiscally sound operation.
Other matters that CMS may require.
CMS has authority to establish reporting requirements for Medicare Advantage
Organizations (MAOs) as described in 42CFR §422.516 (a). Pursuant to that authority,
each MAO must have an effective procedure to develop, compile, evaluate, and report
information to CMS in the time and manner that CMS requires. Additional regulatory support
for the Medicare Part C Reporting Requirements is also found in the Final Rule entitled
“Medicare Program; Revisions to the Medicare Advantage and Prescription Drug Program”
(CMS 4131-F).
All Part C Reporting Requirements documents will be posted at: Centers for Medicare &
Medicaid Services Part C Reporting Requirements website. CMS believes providing these
separate instructions will better serve the organizations reporting these data, while
satisfying the Paperwork Reduction Act requirements.
Commented [SS1]: As a team, agreed we do not need this
paragraph.
Commented [SS2]: We agreed as a group to remove this,
and remove the equivalent in Part D RR doc.
Organizations for which these specifications apply are required to collect these data.
Reporting will vary depending on the plan type and reporting section. Most reporting
sections will be reported annually. Additional Supplemental Benefits Utilization and Cost
inquiries are directed to the following mailbox: https://dpapportal.lmi.org/DPAPMailbox.
Commented [SS3]: We agreed as a group to remove this.
The purpose of this document is to explain what data you
need to collect. This info should be in the PRA statements.
The following data elements listed directly below are considered proprietary, and CMS
considers these as not subject to public disclosure under provisions of the Freedom of
Information Act (FOIA): *
Employer DBA and Legal Name, Employer Address, Employer Tax Identification Numbers
(Employer Group Sponsors)
Commented [SS5]: We agreed to move this to the TS.
*Under FOIA, Plans may need to independently provide justification for protecting these data if a FOIA
request is submitted.
Page 6 of 44
Commented [SS4]: We agreed as a team to remove this
paragraph.
This document lists data elements for each reporting section, reporting timeframes, deadlines,
and required levels of reporting.
Formatted: Right: 0.11", Space Before: 13.75 pt, Line
spacing: Multiple 1.04 li
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.
Commented [SS6]: Sentence moved here from TS
Commented [SS7]: Moved here from TS.
Level of Data Reported
DaIn order to provide guidance to Part C Sponsors on the actual process of entering
reporting requirements data into the Health Plan Management System, a separate Health
Plan Management System (HPMS) Plan Reporting Module (PRM) User Guide may be
found on the PRM start page.ta 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.
Commented [SS8]: Remove, include in TS
Commented [SS9]: We discussed this as a team, even with
Bene or case level reporting, we are only referencing the top
level reporting (contract or plan).
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
Exclusions from Reporting:
1.
2.
3.
4.
5.
6.
7.
Demonstration Plans
Healthcare Prepayment Plan (HCPP) – 1833 Cost Plans
National PACE Plans
Prescription Drug Plans (PDPs) 1
Fallback Plans
Employer/Union Only Direct Contract PDPs1
LI NET Sponsor Plans
0 F
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.
1
Page 7 of 44
Commented [SS10]: List updated based on parameters.
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 months within the reporting period.
zesareData 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
1 F
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-ddata-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-dreporting-requirements-limited-data-set.
Questions
Questions about Part C Reporting Requirements should be sent via email to
PartsCDPlanReportingAndDV@cms.hhs.gov.
2
See 42 CFR § 422.516(g) and § 423.514(j)
Page 8 of 44
Commented [SS11]: Terminations language moved here
from TS,
Commented [SS12]: Run by Michelle: In almost all cases,
a contract cannot report data in HPMS if they are
terminating/have terminated. The contract number will not
pop up in HPMS for submission. Even if they somehow
managed to report, we would not use or look at their data.
Commented [SS13R12]: This language may appear in
other documents and would need to be updated there.
Commented [AL14R12]: Michelle, I advised that we
avoid saying “terminated plans should not report data” aka
should.
Do you think we should state explicitly terminated plans will
not be allowed to report?
Commented [SS15R12]: Alice, Please see if you are ok
with the edits I made at Michelle’s request.
Commented [AL16R12]: OK. Operational “must” is ok
Commented [SS17]: Agreed as a team for 2026, all RR
sections will adopt the same rule as MTM. No enrollment
contracts will NOT show up for any reporting section. No
enrollment contracts will not report data. Their contract
number would not even show up in the HPMS.
Commented [SS18]: The Part C TS had a different
paragraph about DV. However, we agreed as a team to use
the same language that is in the DV manual. The TS will no
longer mention DV as the info is now in the RR doc.
National PACE Plans and 1833 Cost Plans are excluded from reporting all Part C Reporting
Requirements reporting sections.
Page 9 of 44
Commented [SS19]: Removed as it is duplicative of the
new and improved Inclusions and Exclusions section in this
intro.
REPORTING SECTIONS
Reporting Sections
Section I.
GrievancesGRIEVANCES
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.564.
Grievances
According to MMA statute, all MAOs must provide meaningful procedures for hearing and resolving
grievances between enrollees, and the organization or any other entity or individual through which the
organization provides health care services under any MA plan it offers. A grievance is any complaint or
dispute, other than one that constitutes an organization determination, which expresses dissatisfaction with
any aspect of an MA organization’sMAOs or provider’s operations, activities, or behavior, regardless of
whether remedial action is requested. MA organizationsMAOs are required to notify enrollees of their
decision no later than 30 days after receiving their grievance based on the enrollee’s health condition. An
extension up to 14 days is allowed if it is requested by the enrollee, or if the organization needs additional
information and documents that this extension is in the interest of the enrollee. An expedited grievance that
involves refusal by an MA organizationMAO to process an enrollee’s request for an expedited
organization determination or reconsideration requires a response from the MA organization MAO within
24 hours.
I.
Organization Types Required to
Report
-
Commented [SS21]: Streamlined to point to policy,
instead of restating specific policies which may change.
Same for all sections.
GRIEVANCES
This reporting section requires an upload.
-
Commented [SS20]: Updates in citations
provided/approved by SMEs.
01 – Local Coordinated Care
Plan (CCP)
Medicare Savings Accounts (02
– MSAs)
03 – Religious Fraternal Benefit
(RFB) PFFS Private Fee for
Services (PFFS))
04 – Private Fee for Services
(PFFSS)
06 – 1876 Cost
11 – Regional CCP
14 – Employer/Union Only
Direct Contract Employee
Union Direct (ED)- PFFS
15 – RFB Local CCP
Page 10 of 44
Report
Frequency,
Level
1/Year
/Contract Llevel
Commented [SS22]: These sentences were removed as
this information is now in TS.
Report Period Data Due
(s)
Date(s)
Q1: 1/1-3/31
Q2: 4/16/30
Q3: 7/1-9/30
Q4: 10/1-12/31
(Rreporting will
include eachat
quarterly level)
First Monday of
February ofin the
following year.
Data Validation
required.
Commented [SS23]: These tables in each RR section have
all been updated to match the 2025 parameters. The changes
were already discussed with SMEs as needed in 2025
parameters process.
Commented [SS24]: As a team, we agreed to remove the
numbers associated with contract org type, as they are not
meaningful to contracts.
-
17 – Employer/Union Only Direct
Contract Employee Union Direct
(ED) - LPPOLocal CCP
Organizations should include all
800 series plans.
Employer/Union Direct Contracts
should also report this reporting
section, regardless of organization
type.
Page 11 of 44
Commented [SS25]: This contract types was not included
in previous RR docs, however that was an oversight. No
contracts actually have this Org type so it is only here for
completeness. You may see similar instances in other
parameters tables. The explanation is the same in each
instance.
Data Element ID
A.
B.
C.
D.
E.
Page 12 of 44
Data Element Description
Number of Total Grievances
Number of Total Grievances in which timely notification was given
Number of Expedited Grievances
Number of Expedited Grievances in which timely notification was
given
Number of Dismissed Grievances
Section II. Organization Determinations & ReconsiderationsORGANIZATION
DETERMINATIONS & RECONSIDERATIONS
Title 42 CFR, Part 422, Subpart M outlines organization determination and
reconsideration requirements for MA Osorganizations, including timeframes for handling
determinations, and further described in the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance..
Organizations will report quarterly data on an annual basis at the Contract level. Data
files to be uploaded through the HPMS at the Contract level, following the templates
provided in HPMS.
This section requires a file upload.
Organization Types Required to
Report
Report
Frequency,
Level
-
Q1: 1/1-3/31
1/Year
Contract Level Q2: 4/1- 6/30
Q3: 7/1-9/30
Q4: 10/1-12/31
-
01 – Local CCP
02 – MSA
03 – RFB PFFS
04 – PFFS
06 – 1876 Cost
11 – Regional CCP
Employer/Union Only
Direct Contract PFFS
14 – ED-PFFS
Commented [SS26]: Shafa, I am highlighting that
Michelle added this.
Commented [SA27R26]: Perfect thank you.
Commented [SA28R26]: There is a section after this
paragraph that is removed. I want to discuss it further as a
team.
Report Period(s) Data Due
Date(s)
(Rreporting
at quarterly
level)
Last Monday
of February
ofin the
following
year.
Data
Validation
required.
15 – RFB Local CCP
Employer/Union Only
Direct Contract Local
CCP17 – ED-LPPO
Organizations should include all 800
series plans.
Employer/Union Direct Contracts
should also report this reporting
section, regardless of organization
type.
Page 13 of 44
Commented [SA29R26]:
Commented [AL30R26]: Thanks Shafa! I am good with
MBK’s addition of the MEAG guidance link. Since the
reporting periods are listed in the table here, I am ok with not
writing it out in paragraph form.
Commented [SA31]: Approved by the SME
Subsection 1: Organization Determinations
Data
Element ID
A.
Data Element Description
B.
Number of Organization Determinations - Withdrawn
C.
D.
Number of Organization Determinations - Dismissals
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)
Total Number of Organization Determinations mMade in the Reporting
Period Above
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
Number of Organization Determinations – Fully Favorable (Services)
Requested by Non-contract Provider
B.
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
Number of Organization Determinations – Partially Favorable
(Services) Requested by Non-contract Provider
F.
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
Page 14 of 44
Commented [SS32]: This used to be one big table, not has
been split into different tables by subsection to help with
508. The subsection names used to be in the table, and have
now been taken out of the table and made into headings. The
subsection names have not changed.
Data Element
ID
Data Element Description
I.
Number of Organization Determinations – Adverse (Services)
Requested by enrollee/representative or provider on behalf of the
enrollee
Number of Organization Determinations – Adverse (Services)
Requested by Noncontract Provider
J.
K.
Number of Organization Determinations – Adverse (Claims)
Submitted by enrollee/representative
L.
Number of Organization Determinations – Adverse (Claims)
Submitted by Noncontract Provider
Commented [SS32]: This used to be one big table, not has
been split into different tables by subsection to help with
508. The subsection names used to be in the table, and have
now been taken out of the table and made into headings. The
subsection names have not changed.
Subsection 3: Reconsiderations
Data Element
ID
Data Element Description
A.
Total number of Reconsiderations Mmade in Reporting Time Period
Above
Number of Reconsiderations - Withdrawn
Number of Reconsiderations - Dismissals
Number of Reconsiderations requested by or on behalf of the
enrollee (Services)
B.
C.
D.
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
Page 15 of 44
Commented [SS33]: When we say “above” what are we
referring to? Should this just say “in the reporting period”?
Commented [SA34R33]: Discussion with Alice and we
remove “above”.
Commented [SA35R33]: We looked at other reporting
section language and we decided to change it to Reporting
Period to be consistent.
Commented [AL36R33]: I am wondering do we need to
state this at all. We do not say ODs in the reporting period.
Commented [SA37R33]: It would say: Total number of
Reconsiderations made.
In Subsection 1: Organization Determination, Element A
says: Total Number of Organization Determinations Made in
the Reporting Period.
I am going to remove that as well.
I also checked the file layout for Part C ODR, and it says in
the description, Enter the Total number of Reconsiderations
Made in Reporting Time Period for Reconsiderations. So we
should be good.
Commented [SA38R33]: Side note, I would like to
change the file layout for next year. It isn't very intuitive.
Commented [SA39R33]: We decided to remove the
reference for reporting period since we have it in the table
above.
Data Element
ID
Data Element Description
E.
Number of Reconsiderations – Partially Favorable (Services)
requested by enrollee/representative or provider on behalf of the
enrollee
Number of Reconsiderations – Partially Favorable (Services)
requested by Noncontract Provider
F.
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 Noncontract Provider
K
Number of Reconsiderations – Adverse (Claims) submitted by
enrollee/representative
L.
Number of Reconsiderations – Adverse (Claims) submitted by Noncontract Provider
Subsection 5: Re-Openings
Data Element
ID
Data Element Description
A.
Total number of reopened (revised) decisions, for any reason, in Time
Period Above
B.
Contract Number
Commented [SS41]: Should this say “in the reporting
period”?
C.
Case ID
Commented [SA42R41]: Discussion with Alice we
changed to Reporting period to be consistent with other
sections.
D.
Case level (Organization Determination or Reconsideration)
Commented [SA43]: Should we remove this as well,
following the same pattern as OD and reconsiderations?
E.
Date of original disposition
Commented [SS44R43]: If this was resolved, please
delete this comment.
F.
Original disposition (Fully Favorable, Partially Favorable, or Adverse)
Commented [SA45R43]: I removed the language
referencing the reporting period since it is mentioned in the
table above.
G.
Was the case processed under the expedited timeframe? (Y/N)
H.
Case type (Service or Claim)
Page 16 of 44
Commented [SS40]: For 2027, we are considering
removing Element A (both here and in CDR)
Commented [SS46]: Information about file upload that
used to be in the second row of this table has been moved to
the TS as all info about file upload and data entry is now in
the Tech Specs.
Data Element
ID
Data Element Description
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) 3
N.
Reopening disposition (Fully Favorable; Partially Favorable, Adverse
or Pending)
2 F
The date of disposition is the date the required written notice of a revised decision was sent per §
405.982.
3
Page 17 of 44
Commented [SA47]: We removed the citation to the TS
Section III. EMPLOYER Employer GROUP Group PLAN Plan
SPONSORSSponsors
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/regulationsand-guidance/guidance/manuals/downloads/mc86c09.pdf).This reporting section
requires a file upload.
Organization Types
Required to Report
0
-
– Local CCP
– MSA
RFB PFFS
04 – PFFS
06 – 1876 Cost
10 - PDP
11 – Regional CCP
Employer/Union Only
Direct Contract 13 – EDPDPs
- Employer/Union Only
Direct Contract
PFFS
- RFB Local CCP
- Employer/Union Only Direct
Contract Local CCP
14 – ED-PFFS
15 – RFB Local CCP
17 – ED-LPPO
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.
Page 18 of 44
Report
Frequency,/
Level
Report
Period (s)
1/Yyear
PBP Level
1/1 - 12/31
(Reporting at
annual level)
Data Due Date (s)
First Monday of
February ofin the
following year.
Data Validation
not required.
Commented [SS48]: I updated the title of this section to
match 1. the title in HPMS and 2. The title in Part C
documentation.
Data
Element
ID
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 data Eelement H is “N", provide non-calendar year start date.
J.
Current/Anticipated enrollment
Page 19 of 44
Data Element Description
Section IV. Special Needs PLANS Plans (SNPs) CARE Care
MANAGEMENTManagement
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.
Commented [SA49]: Approved by SME
This reporting section requires a file upload into HPMS.
Organization Types
Required to Report
SNP PBPs under the
following types:
-
Report
Frequency,
Level
1/Year
PBP Level
01 – Local CCP
11 – Regional CCP
15 – RFB Local
CCP
Report
Period (s)
1/1-12/31
(Reporting
at annual
level)
Data Due Date (s)
Last Monday of
February in the
following year.
Data Validation required.
Only SNP Plans are required
to report.
Organizations should exclude
800 series plans if they are
SNPs.
Data
Element ID
A.
Data Element Description
B.
Number of new enrollees due for an Initial Health Risk Assessment
(HRA)
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
Number of annual reassessments performed on enrollees eligible for a
reassessment
Number of annual reassessment refusals
F.
G.
H.
Number of annual reassessments where SNP is unable to reach an
enrollee
Notes:
Page 20 of 44
Commented [SS50]: This was here incorrectly. Fixed for
2026.
Commented [SS51]: Added for additional clarity from the
2025 Parameters document.
If a new enrollee does not receive an initial HRA within 90 days of enrollment
that enrollee’s annual HRA is due to be completed within 365 days of
enrollment. A new enrollee who receives an HRA within 90 days of enrollment is
due to complete a reassessment HRA no more than 365 days after the initial
HRA was completed.
Page 21 of 44
Commented [SS52]: Removed as these notes are in the TS
under HRA Reporting Timeline.
Page 22 of 44
Section V.
ENROLLMENT Enrollment andAND DISENROLLMENTDisenrollment
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. CMS will collect data on the elements for these requirements, which are
otherwise not available to CMS, in order to evaluate the sponsor’s processing of
enrollment, disenrollment and reinstatement requests in accordance with CMS
requirements.
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.
Commented [SS53]: Agreed as a team to remove this, as
it is fluff. The introductions should just be citations of
policy/regs, possible links if relevant.
Commented [SS54]: Moved here from TS.
For more information on these requirements, refer to the Medicare AdvantageMA and
Part D Enrollment and Disenrollment Guidance, available at:
https://www.cms.gov/medicare/enrollment-renewal/part-d-enrollment-eligibility.
This reporting section requires a file upload into HPMS.
Organization Types
Required to Report
-
Reporting
Frequency,
Level
2/Year
Report
Period(s)
Data Due date (s)
MAOs offering MA- only
Last Monday of
Period 1:
August (1/16/30)
(no Part D) plans)
Contract Level 1/1-6/30
- 01-Local CCP
Period 2:
Last Monday of
- 03-RFB PFFS
7/1February ofin the
- 04-PFFS
12/31
following year. (7/1- 1876 Cost (PBPs that do
(Reporting at bi- 12/31)
not include a Part D
Data Validation not
annual level)
optional supplemental
required.
benefit)
- 11-Regional CCP
- 15-RFB Local CCP
CMS provides guidance for MAOs and Part D sponsors’ processing of enrollment and
disenrollment requests.
Page 23 of 44
Commented [SS55]: These specific contract types have
been added for clarity, and to be consistent with the way the
other parameters tables are laid out. It does not indicate any
changes in the types of contracts required to report this
section.
Commented [SS56]: Removed sentence as it provides no
real information.
Page 24 of 44
Subsection 1: Enrollment
For questions specific to enrollment/disenrollment requirements please contact the
following mailbox: https://enrollment.lmi.org/deepmailbox.
Commented [SS57]: Removed as we are no longer
sending people to these mailboxes. SMEs have been
informed.
Data Element
Data Element Description
ID
A.
The total number of enrollment requests (i.e., requests initiated by the
beneficiary or his/her authorized representative) received in the
specified timereporting period. Do not include auto/facilitated or
passive enrollments, rollover transactions, or other enrollments
effectuated by CMS.
B.
Of the total reported in Element A, the number of enrollment requests
complete at the time of initial receipt (i.e., required no additional
information from applicant or his/her authorized representative).
C.
Of the total reported in Element A, the number of enrollment requests
that were not complete at the time of initial receipt and for which the
sponsor was required to request additional information from the
applicant (or his/her authorized representative).
D.
Of the total reported in Element A, the number of enrollment requests
denied due to the sponsor’s determination of the applicant’s ineligibility
to elect the plan (i.e., individual not eligible for an election period).
E.
Of the total reported in Element C, the number of incomplete enrollment
request received that are incomplete upon initial receipt and completed
within established timeframes.
F.
Of the total reported in Element C, the number of enrollment requests
denied due to the applicant or his/her authorized representative not
providing information to complete the enrollment request within
established timeframes.
G.
Of the total reported in Element A, the number of paper enrollment
requests received.
H.
Of the total reported in Element A, the number of telephonic enrollment
requests received (if sponsor offers this mechanism).
I.
Of the total reported in Element A, the number of electronic enrollment
requests received via an electronic device or secure internet website (if
sponsor offers this mechanism).
J.
Of the total reported in Element A, the number of Medicare Online
Enrollment Center (OEC) enrollment requests received.
Commented [SS58]: Slight edits made throughout to
match Part D document.
Commented [SS59]: We ensured we always say
“authorized representative” so that we are consistent between
C and D rr docs. Note that while the Part C reg says
“authorized representative”, the Part D reg just says
“Representative”.
Commented [SS60]: For 2027, The Part D RR doc has an
element K: Of the total reported in A, the number of
enrollment requests received from an applicant through an
agent or broker.
Alice said we should talk to SMEs about adding for 2027.
Page 25 of 44
Subsection 2: Disenrollment
Data Element
ID
Data Element Description
A.
The total number of voluntary disenrollment requests received in the
specified time period 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
complete 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.
Page 26 of 44
Commented [SS61]: For 2027, Part D has three elements
in disenrollment that do not exist here. In Part D those are
element C, E, and F.
Alice said for 2027 we should talk to the SMEs about adding
these elements to Part C.
Commented [SS62]: This used to be one big table, not has
been split into different tables by subsection to help with
508. The subsection names used to be in the table, and have
now been taken out of the table and made into headings. The
subsection names have not changed.
Section VI. Rewards and Incentives ProgramsREWARDS 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
-
1/Year,
1/1-12/31
Last Monday
Contract Level, (Reporting at of February in
annual level) of the
Partial Data
following year.
Entry and File
Upload
Data
Validation not
required.
01 – Local CCP
02 – MSA
- 03 – RFB PFFS
- 04 – PFFS
- 11 – Regional CCP
- Employer/Union Only
Direct Contract PFFS
- RFB Local CCP
- Employer/Union Only Direct
Contract Local CCP
14 – ED-PFFS
15 – RFB Local CCP
17 – ED – LPPO
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.
A plan user needs to select "Yes" or "No" for data element A. on the edit page. If
the plan user selected "No," no upload is necessary. If the plan user selects "Yes,"
then the user will be required to upload additional information in accordance with
the file record layout.
Page 27 of 44
Commented [SS63]: This information has been moved to
the TS.
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? [Text]
D.
What reward(s) may enrollees earn for participation? [Text]
E.
How do you calculate the value of the reward? [Text]
F.
How do you track enrollee participation in the program? [Text]
G.
H.
How many enrollees are currently enrolled in the program? [NUM]
How many rewards have been awarded so far? [NUM]
Page 28 of 44
Commented [SS64]: Removed as this information is in the
file layouts.
Commented [SS65]: For 2027: Alice noted that these data
elements are so different than the others. For ex, element G other sections would say, “the number of enrollees enrolled
in the program”. (Currently does not seem correct since data
reported for the full CY).
Possible 2027 substantive changes to this section.
Section VII. Payments to ProvidersPAYMENTS TO PROVIDERS
The Department of Health and Human Services (Collecting these data will help to inform
us as we determine how broadly MA organizations are using alternative payment
arrangements. See Technical Specs for additional information.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://hcplan.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. of the four
categories are as follows:
Category one includes a fee-for-service with no link to quality arrangement to
include all arrangements where payments are based on volume of services and
not linked to quality of efficiency.
Category two includes fee-for-service with a link to quality to include all
arrangements where at least a portion of payments vary based on the quality or
efficiency of health care delivery including hospital value-based purchasing and
physician value-based modifiers.
Category three includes alternative payment models built on fee-for-service
architecture to include all arrangements where some payment is linked to the
effective management of a population or an episode of care. Payments are still
triggered by delivery of services, but there are opportunities for shared savings or
2-sided risk.
Category four includes population-based payment arrangements to include some
payment is not directly triggered by service delivery so volume is not linked to
payment. Under these arrangements, clinicians and organizations are paid and
responsible for the care of a beneficiary for a long period (e.g., greater than a
year).
CMS will also collect data on the number of lives MA organizations have attributed,
aligned, assigned, empaneled, or otherwise associated with accountable care
arrangements. Under such arrangements providers have accountability for quality and
total cost of care for a period of at least six months (i.e. a longitudinal, aligned care
relationship between the beneficiary and clinician/provider). For additional detail on the
definition of these concepts, please see LAN Guidance on Measuring Covered Lives in
Accountable Care APM Arrangements and APM Data Collection Tool found here
(https://hcp-lan.org/data-collection-process/#1601909304600-3b650088-e3e1).
Page 29 of 44
Formatted: Right: 0"
Commented [SS66]: Bindu, Michelle requested to strike
these first two sentences. I have done so because I agree (see
in all markup). We agreed we are not saying why we
collected specific data, and we are not referencing TS in
these RR sections.
Commented [BA67R66]: Agree. Thank you.
Commented [SS68]: This paragraph was moved here from
the TS.
Commented [SS69]: Removed as SME said second
paragraph suffices along with link to policy guidance.
Organization
Types Required
to Report
01 – Local CCP
04 – PFFS
11 – Regional CCP
15 – RFB Local CCP
Data
Element ID
A.
Report
Report
Frequency, Level Period(s)
1/Year,
Contract Level,
File Upload
Data Due Date(s)
1/1-12/31
Last Monday of February
(Reporting at ofin the following year.
annual level)
Data Validation not
required.
Data Element Description
Total dollars paid to providers (in and out of network) for Medicare
Advantage enrollees in [CY 20XX] or most recent 12 months.
Commented [SS70]: Removed as this should be inferred.
Subsection 1: Category 1
Data
Element ID
B.
Data Element Description
Total dollars paid to providers through legacy payments (including feefor-service (i.e., payments made for units of service) in [CY 20XX] or
most recent 12 months 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 in [CY
20XX] or most recent 12 months..
Subsection 2: Category 2
Data
Element ID
C.
Data Element Description
D.
Total dollars paid to providers through fee-for-service plus pay-forperformance payments (linked to quality) in [CY 20XX] or most recent 12
months.
Dollars paid for foundational spending to improve care (linked to quality)
in [CY 20XX] or most recent 12 months.
E.
F.
Page 30 of 44
Total dollars paid to providers through fee-for-sService plus pay-forreporting payments (linked to quality) in [CY 20XX] or most recent 12
months.
Total dollars paid in Category 2 in [CY 20XX] or most recent 12 months.
Commented [SS71]: This used to be one big table, not has
been split into different tables by subsection to help with
508. The subsection names used to be in the table, and have
now been taken out of the table and made into headings. The
subsection names have not changed.
Subsection 3: Category 3
Data
Element ID
G.
H.
I.
J.
K.
L.
Data Element Description
Total dollars paid to providers through traditional shared-savings (linked
to quality) payments in [CY 20XX] or most recent 12 months.
Total dollars paid to providers through utilization-based shared-savings
(linked to quality) payments in [CY 20XX] or most recent 12 months.
Total dollars paid to providers through fee-for-service-based shared-risk
(linked to quality) payments in [CY 20XX] or most recent 12 months.
Total dollars paid to providers through procedure-based
bundled/episode payments (linked to quality) programs in [CY 20XX] or
most recent 12 months.
Total dollars paid in Category 3 in [CY 20XX] or most recent 12 months.
Total Risk-based payments not linked to quality (e.g., 3N in APM
definitional framework).
Subsection 4: Category 4
Data
Element ID
M.
N.
O.
P.
Q.
R.
S.
Page 31 of 44
Data Element Description
Total dollars paid to providers through condition-specific, populationbased payments (linked to quality) in [CY 20XX] or most recent 12
months.
Total dollars paid to providers through condition-specific,
bundled/episode payments (linked to quality) in [CY 20XX] or most
recent 12 months.
Total dollars paid to providers through population-based payments that
are NOT condition-specific (linked to quality) in [CY 20XX] or most
recent 12 months.
Total dollars paid to providers through full or percent of premium
population- based payments (linked to quality) in [CY 20XX] or most
recent 12 months.
Total dollars paid to providers through integrated finance and delivery
system programs (linked to quality). in [CY 20XX] or most recent 12
months.
Total dollars paid in Category 4 in [CY 20XX] or most recent 12 months.
Total capitation payment not linked to quality (e.g., 4N in the APM
definitional framework).
Subsection 5: Provider Data
Data
Element ID
T.
Data Element Description
U.
Total Medicare Advantage contracted providers paid on a fee-forservice basis with no link to quality (Ccategory 1)
Total Medicare Advantage contracted providers paid on a fee-forservice plus pay- for-reporting payments (linked to quality)
Total Medicare Advantage contracted providers paid on a fee-forservice plus pay- for-performance payments (linked to quality)
Total Medicare Advantage contracted providers paid on a fee-for-service
basis with a link to quality (Ccategory 2)
Total Medicare Advantage contracted providers paid based on
alternative payment models built on a fee-for-service architecture
(Category 3)
Total Medicare Advantage contracted providers paid through traditional
shared savings (linked to quality)
Total Medicare Advantage contracted providers paid through utilizationbased shared- savings (linked to quality)
Total Medicare Advantage contracted providers paid through fee-forservice-based shared- risk (linked to quality)
Total Medicare Advantage contracted providers paid through
procedure-based bundled/episode payments (linked to quality)
Total Medicare Advantage contracted providers paid based through
risk-based payments not linked to quality (e.g., 3N in the APM
definitional framework)
Total Medicare Advantage contracted providers paid through based on
through population-based payments (Ccategory 4)
Total Medicare Advantage contracted providers paid through based on
condition-specific, population-based payments (linked to quality)
Total Medicare Advantage contracted providers paid through conditionspecific, bundled/episode payments (linked to quality)
Total Medicare Advantage contracted providers paid through populationbased payments that are NOT condition-specific (linked to quality)
Total Medicare Advantage contracted providers paid through full or
percent of premium population-based payments (linked to quality)
Total Medicare Advantage contracted providers paid through integrated
finance and delivery system programs (linked to quality)
Total Medicare Advantage contracted providers paid based on capitation
with no link to quality (e.g., Ccategory 4N in the APM definitional
framework)
V.
W.
X.
Y.
Z.
AA.
BB.
CC.
DD.
EE.
FF.
GG.
HH.
II.
JJ.
KK.
Page 32 of 44
Total number of Medicare Advantage contracted providers
Commented [SS72]: Corrected this throughout, SME said
should say “paid through”
Subsection 6: PCP/PCG-Focused Accountable Care Metrics
(Metrics below apply to the number of MA plan enrollees in an accountable care
arrangements. Metrics are linked to quality.)
Data Element Description
Data
Element ID
Total Medicare Advantage covered lives in [CY 20XX] or most recent
LL.
12 months.
Total number of Medicare Advantage health plan enrollees
MM.
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 in [CY 20XX] or most recent
12 months. [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
arrangements. Metrics are linked to quality.)
Data
Data Element Description
Element ID
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 in [CY 20XX]
or most recent 12 months. [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)].
Page 33 of 44
Section VIII.
Supplemental Benefit Utilization and CostsSUPPLEMENTAL
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)
-
1/year
; PBP Level
1/1-12/31
(Reporting at
annual level)
Last Monday in
February of the
following calendar year
-
01 – Local
CCP
02 – MSA
03 – RFB PFFS
04 – PFFS
Data Validation not
required.
06 – 1876 Cost
11 – Regional
CCP
- Employer/Union Only
Direct Contract PFFS
- RFB Local CCP
- Employer/Union Only
Direct Contract Local
CCP
12-14 – ED-PFFS
13-15 – RFB Local CCP
17- ED_LPPO
Organizations should
include all 800 series plans.
Employer/Union Direct
Contracts should also report
this reporting section,
regardless of organization
type.
The data elements listed below must be reported for each of the following
supplemental benefits:
Page 34 of 44
PBP Category
Supplemental Benefit
Inpatient Hospital Services
1a1
1a2
1a3
1a-B
1b1
1b2
1b-B
Additional Days for Inpatient Hospital-Acute
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Upgrades for Inpatient Hospital-Acute
Inpatient Hospital – Acute Services (For B-Only Plans)
Additional Days for Inpatient Hospital Psychiatric
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Inpatient Psychiatric Hospital Services (For B-Only Plans)
Skilled Nursing Facility Services
2-1
2-3
2-B
Page 35 of 44
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
SNF – Waiver of 3 Day Hospital Stay*
SNF Care (For B-Only Plans)
Commented [SS73]: Removed, as it is duplicative of TS.
Cardiac and Pulmonary Rehabilitation Services
3-1
3-2
3-3
3-4
Additional Cardiac Rehabilitation Services
Additional Intensive Cardiac Rehabilitation Services
Additional Pulmonary Rehabilitation Services
Additional Supervised Exercise Therapy (SET) for Peripheral Artery
Disease (PAD) Services
Worldwide Emergency/Urgent Coverage
4c1
4c2
4c3
Worldwide Emergency Coverage
Worldwide Urgent Coverage
Worldwide Emergency Transportation
Health Care Professional Services
7b1
Routine Chiropractic Care
7b2
Chiropractic – Other Service
7f
Routine Foot Care
Outpatient Blood Services
9d-1
Three (3) Pint Deductible Waived*
Transportation Services
10b1
Transportation Services to Plan-Approved Health-related Location
10b2
Transportation Services to Any Health-related Location
Other Supplemental Services
13a
13b
13c
13d
13e
13f
Page 36 of 44
Acupuncture Treatments
Over-the-Counter (OTC) Items
Meal Benefits
Other 1
Other 2
Other 3
13g
Page 37 of 44
Dual Eligible SNPs with Highly Integrated Services
Preventive and Other Defined Supplemental Services
14b
14c1
14c2
14c3
14c4a
14c4b
14c4c
14c5
14c6
14c7a
14c7b
14c8
14c9
14c10
14c11
14c12
14c13
14c14
14c15
14c16
14c17
14c18
14c19
Annual Physical Exam
Health Education
Nutritional/Dietary Benefit
Additional Smoking and Tobacco Cessation Counseling
Fitness Benefit – Physical Fitness*
Fitness Benefit – Memory Fitness*
Fitness Benefit – Activity Tracker*
Enhanced Disease Management
Telemonitoring Services
Remote Access Technologies – Nursing Hotline*
Remote Access Technologies – Web/Phone-based Technologies*
Home and Bathroom Safety Devices and Modifications
Counseling Services
In-Home Safety Assessment
Personal Emergency Response System (PERS)
Medical Nutrition Therapy (MNT)
Post Discharge In-home Medication Reconciliation
Re-admission Prevention
Wigs for Hair Loss Related to Chemotherapy
Weight Management Programs
Alternative Therapies
Therapeutic Massage
Adult Day Health Services
14c20
14c21
14c22a
14c22b
14c22c
Home-Based Palliative Care
In-Home Support Services
Support for Caregivers of Enrollees – Respite Care*
Support for Caregivers of Enrollees – Caregiver Training*
Support for Caregivers of Enrollees – Other*
Dental
16b1
16b2
16b3
Page 38 of 44
Oral Exams
Dental X-Rays
Other Diagnostic Dental Services
16b4
16b5
16b6
16c1
16c2
16c3
16c4
16c5
Prophylaxis (cleaning)
Fluoride Treatment
Other Preventive Dental Services
Restorative Services
Endodontics
Periodontics
Prosthodontics, removable
Maxillofacial Prosthetics
16c6
Implant Services
16c7
Prosthodontics, fixed
16c8
Oral and Maxillofacial Surgery
16c9
Orthodontics
16c10
Adjunctive General Services
Eye Exams/Eyewear
17a1
Routine Eye Exams
17a2
17b1
17b2
17b3
17b4
17b5
Other Eye Exam Services
Contact Lenses
Eyeglasses (Lenses and Frames)
Eyeglass Lenses
Eyeglass Frames
Eyewear Upgrades
Hearing Exams/Hearing Aids
18a1
Routine Hearing Exams
18a2
18b1
18b2
18b3
18b4
Fitting/Evaluation for Hearing Aid
Prescription Hearing Aids (All Types)
Prescription Hearing Aids – Inner Ear
Prescription Hearing Aids – Outer Ear
Prescription Hearing Aids – Over the Ear
18c
OTC Hearing Aids
Medicare covered services offered as POS or V/T
VT
Page 39 of 44
Visitor/Travel Program (Medicare Covered benefits)*
POS
Point of Service (Medicare Covered benefits)*
Non-Primarily Health Related Benefits**
13i1
13i2
13i3
13i4
13i5
13i6
13i7
Food and Produce
Meals (Beyond limited basis)
Pest Control
Transportation for Non-Medical Needs
Indoor Air Quality Equipment and Services
Social Needs Benefit
Complementary Therapies
13i8
13i9
13i10
13i-11
13i-12
13i-13
13i-14
13i-15
Services Supporting Self-Direction
Structural Home Modifications
General Supports for Living
Non-Primarily Health Related Benefits for the Chronically Ill Other 1
Non-Primarily Health Related Benefits for the Chronically Ill Other 2
Non-Primarily Health Related Benefits for the Chronically Ill Other 3
Non-Primarily Health Related Benefits for the Chronically Ill Other 4
Non-Primarily Health Related Benefits for the Chronically Ill Other 5
Page 40 of 44
*Benefit category code has been defined for purposes of collecting these data for the Part C Reporting
Requirements. These codes are not part of the CY 2025 Plan Benefit Package (PBP).
**Non-Primarily Health Related Benefits are only available as Special Supplemental
Benefits for the Chronically Ill (SSBCI)
The following data elements must be reported:
Data
Element ID
A.
B.
C.
D.
E.
F.
Data Element Description
Contract ID
PBP ID
PBP Category
Supplemental benefit name, if the PBP Category (Element C) has an
“Other” designation “Other” (Only enter information for the following
PBP categories: 7b2, 13d, 13e, 13f, or 13i-11 throughthrough 13i-15,
and 17a2). The text entered for Element D should be the
supplemental benefit name that the plan submitted in the PBP for the
CY of the reporting period. O), or if name otherwise differs from
values provided
above.
How is the supplemental benefit offered?
(Mandatory, Optional, Uniformity Flexibility, SSBCI, not offered)
If the same supplemental benefit (as identified by a specific PBP
Category) is offered in multiple ways (e.g., as an optional benefit,
and also as an SSBCI), report Data Elements FG-P for each offering
type separately.
Network type (in-network, out-of-network (for PPO), out-of-network (for
HMO-POS), Visitor/travel, Oother).
If “Oother”, specify further in Data Element M, e.g., full network for
PFFS plan.
Similar to Element E, if the same supplemental benefit (as identified by
a specific PBP Category in Element C) is offered in more than one
network type (e.g., as both in-network and out-of-network (for PPO)),
report Elements G-P for each network type separately.
G.
The unit of utilization used by the plan when measuring utilization. For
example, (e.g., admissions, visits, procedures, trips, or purchases.,
This list of examples is not exhaustive. Only one unit of utilization is
allowed per PBP Category.
H.
The number of enrollees ever eligible for the benefit during the reporting
period.
Page 41 of 44
Commented [SS74]: For 2027, consider removing
Contract and Plan ID from Data Element letters and re-letter.
Data
Element ID
I.
J.
K.
L.
Data Element Description
*Plans should include all enrollees ever eligible for this benefit during
the calendar year. This number should not be a ‘point-in time’ number
but rather a unique count of all enrollees who were eligible for the
benefit.
The number of enrollees who utilized the benefit at least once.
The total instances of utilizations among eligible enrollees.
The median number of utilizations among enrollees who utilized the
benefit at least once.
The total net amount incurred by plan to offer the benefit.
NOTE: When computing this amount, report the net amount spent
rather than the gross amount allocated. For example, if the MA plan
allocated $1000 for the enrollee to use for certain dental services, but
the enrollee used only $250, then the MA plan must include only that
$250 in computing the total amount to report under this data element.
Commented [SS75]: This was moved to the TS.
Commented [SS76]: This was moved to the TS.
Similarly, if the MA plan implements the benefit through PMPM
arrangement, and the MA plan recoups some of that amount for any
reason, the MA plan must include only the amount spent rather than
the allocated PMPM amount.
M.
N.
O.
P.
Page 42 of 44
The type of payment arrangement(s) the plan used to implement the
benefit. The plan may use the categories CMS provides in the
Payments to Providers section of the Part C Reporting Requirements.
Alternatively, the plan may use other phrases or provide a brief
description if its payment arrangement does not neatly fall into one of
those categories.
How the plan accounts for the cost of the benefit, including how the
plan determines and measures administrative costs, costs to deliver,
and any other costs the plan captures.
NOTE: CMS will not voluntarily release data collected under this
element to the public, either individually or in the aggregate. This
information will inform future development of cost reporting data
elements in these reporting requirements and may inform how CMS
requires cost reporting in other contexts.
The total out-of-pocket-cost for enrollees who utilized the benefit.
T(Note this should be a sum of all enrollee out- of-pocket costs for a
service category, broken down by the Data Element E).
The median out-of-pocket cost for enrollees.
Commented [SS77]: This was moved to TS.
Commented [SS78]: This was moved to TS.
Section IX. D-SNP Enrollee Advisory Committee
42 CFR § 422.107(f) establishes requirements for Enrollee Advisory Committees for any
MAO organization offering one or more D-SNPs in a state.
Organization Types
Required to Report
D-SNP PBPs under the
following types:
-
Report
Frequency,
Level
1/Year
PBP Level
01 – Local CCP
11 – Regional
CCP 15 – RFB
Local CCP
Data
Element ID
A.
B.
Report
Period(s)
1/1-12/31
(Reporting
at annual
level)
Data Due Date(s)
Last Monday of
February ofin the
following year.
Data Validation not
required.
Data Element Description
Does the D-SNP share an enrollee advisory committee (EAC) with other
D-SNP(s)? (“Yes” or “No” only)
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)
Were auxiliary aids and services offered for each D-SNP EAC
meeting? (“Yes” or “No” only)
E.
Page 43 of 44
Commented [SS79]: This was incorrect and has been
removed.
Section X.
D-SNP Transmission oOf 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
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:
-
Report
Frequency,
Level
1/Year
PBP
Level1/YearPBP
Report
Period(s)
1/1-12/31
Data Due Date(s)
Last Monday of April
ofin the following year.
A.
B.
Page 44 of 44
Formatted Table
(Reporting at
annual level) Data Validation not
required.
01 – Local CCP
11 – Regional
CCP 15 – RFB
Local CCP
Data
Element ID
Commented [BA80]: This citation is from SME.
Data Element Description
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.
Of the total reported in Data 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.
Commented [SS81]: This was incorrect and has been
removed.
| File Type | application/pdf |
| File Title | Part C Reporting Requirements |
| Subject | 2024 Data Validation |
| Author | Sky Gonzalez |
| File Modified | 2025-09-18 |
| File Created | 2025-09-18 |