Because January 1, 2026, will arrive faster than a rejected HPMS login.
CMS just released the official Contract Year (CY) 2026 Readiness Checklist, signed by Vanessa S. Duran and Kathryn A. Coleman — the playbook every MA organization, Part D sponsor, Cost Plan, and PACE program needs to be fully operational by January 1, 2026.
Think of this checklist as the industry’s annual “pre-flight inspection.” If even one lever is out of alignment — HPMS access, data submissions, network adequacy, member communications, PDE timeliness — CMS will catch it.
Let’s walk through it in a fun, interactive way (with a few analogies sprinkled in), while keeping all the details intact.
1. Inflation Reduction Act (IRA): The Big Engine Upgrade
CMS spotlights several major IRA-driven changes going into effect:
🔹 Medicare Drug Price Negotiation Program
10 drugs have newly negotiated Maximum Fair Prices (MFPs) effective Jan 1, 2026.
Plans must ensure payments do not exceed MFP + dispensing fees.
🔹 Part D Redesign
The 2025 overhaul continues:
$2,000 out-of-pocket max
Elimination of the coverage gap
Transition to the Manufacturer Discount Program
Updated TrOOP rules
New definitions for EA benefits
EGWP prospective reinsurance changes
Selected Drug Subsidy establishment
🔹 Medicare Prescription Payment Plan
The monthly payment option is now fully in play for 2025+ and requires:
Correct cost-sharing calculations
Accurate member installment options
CMS reminds plans to keep reviewing related HPMS memos — several were issued between April 2024 and July 2025.
2. Access to Services: Don’t Leave Members Guessing
Plans must ensure:
Call centers provide interpreter services
Required materials delivered in multiple languages
SNPs must follow both Medicare + Medicaid translation standards
Use professional translation methods (no Google Translate shortcuts 😉)
CMS also provides model materials translated into Spanish, Chinese, Korean, and Vietnamese.
3. Accessibility & TTY
Plans must:
Provide all materials in accessible formats upon request
Display TTY numbers alongside customer service numbers
Ensure TTY access works (711 or state relay accepted)
4. Precluded Providers & Prescribers
Plans must:
Notify beneficiaries
Reject services/claims tied to individuals on CMS’s preclusion list
Ensure PBMs reject Part D claims from precluded prescribers
CMS lists the criteria — from Medicare revocation to certain felonies.
5. Systems, Data & Connectivity: The Heart of Readiness
This section is huge — and critical. CMS expects flawless performance across:
✔ HPMS
Ensure staff register in the Plan Connectivity Module
Keep contract contacts updated (CMS uses them frequently!)
✔ Internal & downstream system testing
Examples of failures CMS has seen:
Claims system misfires
Missing EOBs
Incorrect ID card files
Copay miscalculations
Transition fill issues
✔ MARx
Keep enrollment submissions timely
Ensure EPOCs and IDM access are maintained
(IDM locks after 60 days — yes, still.)
✔ Medicare Plan Finder (MPF)
Part D sponsors must:
Submit accurate pricing + pharmacy network files
Perform QA before submission
Correct outlier notifications
Avoid suppression by ensuring accuracy across all MPF data
✔ Patient Safety & OMS
Maintain report access
Review monthly safety data
Address opioid overutilization and safety edits
Follow OMS guidelines for notifications and case management
✔ Encounter Data & RAPS
MA plans must:
Submit complete risk-adjustment data
Resolve errors before deadlines
Use EDS as the primary source for DOS 2021+
Follow supplemental benefits reporting rules (including dental via 837D)
PACE plans must continue transitioning from RAPS to EDS.
✔ PDE & DIR
Part D sponsors must:
Submit PDEs for selected drugs within 7 days
Submit PDEs for all other drugs within 30 days
Submit adjustments/deletes within 90 days
Use CSSC tools, PDE portals, and reconcile PDEs with internal records
Meet DIR reporting and certification requirements
Apply pharmacy price concessions at POS (regulatory requirement)
6. Reporting Requirements
Plans must:
Submit HEDIS®, HOS, CAHPS®
Register with Acumen’s Part C/D Reporting Portal
Follow Reporting Requirements + conduct independent data validation
Return sponsor-identified overpayments within 60 days
Follow guidance for risk-adjustment and PDE/DIR-related overpayments
Maintain audited financial statements for Fiscal Soundness
Implement SNP HRA screening on housing, food, transportation
7. Contracting, Subcontractor Oversight & AWP
Plans must:
Provide Any Willing Pharmacy (AWP) terms by Sept 15
Update offshore subcontractor listings in HPMS within 30 days
Maintain FDR oversight
Adhere to state Medicaid contract requirements for D-SNPs
8. Customer Service & Communications
CMS checks everything:
Call center wait times, language support, and TTY compliance
MTM program requirements
CTM data accuracy
Marketing materials + website + provider directories
Real-Time Benefit Tools (RTBT)
Agent/broker compensation rules
Medicare opioid education requirements
9. Enrollment & Disenrollment
Plans must:
Follow AEP, MA-OEP, SEP rules
Maintain compliant electronic enrollment mechanisms
Ensure 5-Star SEP processes are correct
Monitor LEP, retroactive enrollment, and OEC data
Ensure timely HPMS submissions for enrollment updates
10. Benefits, Protections & Network Requirements
CMS requires:
Part C network adequacy
Part D network access
Formulary compliance
Anti-discrimination protections for dually eligible
Adherence to Coverage Gap & Manufacturer Discount Program rules
Medicare Prescription Payment Plan integration
CCIP compliance
EGWP alignment with EGWP rules
11. LIS, COB & TrOOP
Plans must:
Process LIS benefits accurately
Manage BAE documentation
Support ATBT for TrOOP
Follow COB rules
Handle hospice, ESRD, ABII and transition claims correctly
12. Appeals, Grievances, UM & Emergencies
CMS reminds plans to:
Maintain compliant OD appeals process
Ensure UM Committee functions as required
Follow PHE/disaster declaration rules
Maintain compliance programs and internal monitoring
Final Takeaway: 2026 Readiness Isn’t a Checklist — It’s a Mindset
With IRA redesign, new payment rules, expanded reporting, supplemental benefit submissions, PDE timeliness, and network adequacy convergence — CY 2026 is one of the most operationally complex years yet.
CMS expects plans to:
Identify risks early
Communicate with account managers
Maintain continuous compliance
Test systems proactively
Keep documentation audit-ready