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Key MA and PDP Plan Callouts in the CY2026 CMS Readiness Checklist


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The CY2026 CMS Readiness Checklist was released November 4.  Each year, the Centers for Medicare & Medicaid Services (CMS) releases its Annual Readiness Checklist, outlining the operational, regulatory and compliance requirements that Medicare Advantage (MA) and Part D plans must have in place for the upcoming year.


While many elements are consistent year over year, CMS routinely adds new items and clarifies expectations based on evolving regulations and program priorities. The CY2026 Readiness Checklist introduces several key updates tied to the Inflation Reduction Act (IRA), encounter and risk adjustment submissions, pharmacy contracting, beneficiary protections, and member experience oversight.


Below are the top new or updated requirements plans should prioritize.


Part D – New Additions


  • IRA Implementation of the First 10 Negotiated Drug Maximum Fair Prices (MFPs) – Beginning January 1, 2026, MAPD and PDP plans must not pay more than the MFP and dispensing fee for the 10 negotiated Part D drugs during the price applicability period. Plans should validate pricing logic, system configuration, and reconciliation processes now to ensure compliance.

  • Network Pharmacy Contracting Requirements – Effective January 1, 2026, all network pharmacy contracts must include mandatory enrollment in the MTF Data Module to support IRA drug price negotiation operations. Confirm that your internal and PBM agreements are updated accordingly.

  • Selected Drug Subsidy Program – MAPD and PDP plans will receive a 10% subsidy of the negotiated price for selected drugs covered before a member reaches the Out-of-Pocket threshold. Plans should ensure operational readiness for subsidy management and downstream reporting.

  • PDE Submission Timeliness – For selected drugs (Section 1192(c) of the Social Security Act), initial PDE records must be submitted within seven calendar days of receiving the claim (42 C.F.R. § 423.325(b)). Timely submissions will be closely monitored to ensure compliance.

  • Medicare Prescription Payment Plan – Automatic RenewalStarting with CY2026, Part D sponsors must automatically renew participation for enrollees who remain in the same PBP. Sponsors are required to send renewal notices after AEP and before the start of the plan year (42 C.F.R. § 423.137). Plans participating in 2025 must automatically renew those members for 2026.

 

Part C – New Additions

  • Encounter and RAPS Submissions – CMS continues its focus on encounter and RAPS data integrity. For files to be considered “received,” they must be sent, received, corrected for all errors, and accepted by CMS before the required deadlines.

o   Initial, mid-year, and final deadlines remain strict and binding.

o   Diagnosis codes submitted after the final deadline will not be included in payment.

o   Plans should schedule submission cycles throughout the year to allow adequate time for validation and error correction.

  • Complaint Tracking Module (CTM) – Plans must now include a direct link to the Medicare.gov complaint portal on their main MA or PDP product website. Verify that the link is active and functioning properly.

 

The CMS Readiness Checklist is an invaluable resource to validate your plan’s operational, compliance, and systems readiness for the upcoming year. While these may be new or updated callouts, it’s essential to review the entire checklist to ensure full alignment and preparedness ahead of the CY2026 new plan year.


At Rebellis Group, we help health plans navigate every aspect of Medicare Advantage and Prescription Drug Program readiness — from compliance validation and operational assessments to implementation support.


If you need help staying on top of regulatory summaries, we offer a subscription service that delivers key updates straight to your inbox. Ask us how to get started.

 


 
 
 
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