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CMS Releases 2026 Program Audit Updates — What Plans Need to Know

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CMS just issued its 2026 Program Audit Annual Update, and there are several major shifts that Medicare Advantage, Part D, and Cost Plans should begin preparing for now.


Below are the key takeaways:


1. Audit Scoring Is Eliminated

  • CMS is removing all audit scoring beginning in 2026.

  • Conditions will no longer carry points, and CMS may consider alternative weighting methods in the future.


2. Condition Classifications Are Simplified

CMS is retiring ICAR and ORCA categories. New structure:

  • Observation – Noncompliance that does not require a corrective action plan.

  • CAR (Corrective Action Required) – Noncompliance that requires remediation to prevent recurrence or address enrollee impact.

  • IDS (Invalid Data Submission) – Used when a plan cannot provide accurate or complete universes/documentation.


3. Shift in Evaluating Compliance Program Effectiveness (CPE)

  • CMS will pilot a new approach focusing on how compliance programs prevent/detect/correct noncompliance.

  • Emphasis shifts from policies/procedures to real-time operational integration.

  • Compliance officers will have in-depth discussions with CMS during fieldwork on monitoring, root cause analysis, and corrective actions.

  • CPE-specific findings will typically not be cited in 2026, unless structural compliance issues are discovered.


4. New Quarterly Compliance Officer Calls

  • CMS will begin quarterly educational calls with Compliance Officers.

  • Designed to share insights, discuss best practices, and collaborate across industry on common audit findings.


5. Validation Audit Requirements Are Refined

Starting in 2026:

  • CMS will determine the level of validation needed for each CAR.

  • Simple fixes (e.g., template language updates) may be validated directly by CMS without a full IVA.

  • Findings requiring deeper testing will be labeled “in need of a validation audit.”

  • Independent auditors only required when a Sponsor has more than five conditions needing a validation audit (vs. 2025’s broader threshold).


6. Audit Timing and Operational Notes

  • Engagement letters will be issued Feb–Aug 2026.

  • Fieldwork remains within a two-week window, with CPE integrated into the workflow.

  • CMS will continue heightened assessment of coverage and UM compliance as finalized in CMS-4201-F.

  • Collection of several tables remains suspended (e.g., FA Table 3 PDE, CDAG CARA metrics, ODAG D-SNP AIP table).


7. Additional Transparency Resources Available

CMS continues to provide:


Stay ahead of every CMS update—without the overwhelm.


Rebellis can prepare your organization for the 2026 audit shift and deliver streamlined regulatory next steps straight to your inbox. Ask us how you can secure your package now to ensure expert support at the ready as these CMS changes take effect.



 
 
 
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