Beacon Alert 2025-048 Weekly Regulatory Updates
The Centers for Medicare & Medicaid Services (CMS) issued several critical updates between November 24 and 28, 2025, impacting Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), and other stakeholders. This summary highlights the most significant changes you need to know to stay compliant and informed.
1. Parts C & D Reporting: New Data Files Available
CMS has released the CY 2024 Parts C & D Reporting Requirements Limited Data Set Files. These datasets support transparency and facilitate accurate reporting. MAOs are encouraged to review and incorporate this information into their compliance programs.
2. Encounter Data Report Cards – Q3 2025
New Q3 2025 Encounter Data Report Cards are now available in HPMS. These tools help MAOs identify gaps in encounter data submissions and offer technical support where needed. The reports can be found in:
HPMS → Risk Adjustment → Encounter Data → Encounter Data Report → 2025 November Update
Non-compliance in data submission can trigger CMS interventions, so it’s essential for plans to review their data integrity regularly.
3. Clarification on NCDs with Coverage with Evidence Development (CED)
CMS clarified that Medicare Advantage Organizations may not apply internal coverage criteria to National Coverage Determinations (NCDs) that include CED. These NCDs are considered fully established under 42 CFR § 422.101(b)(6), meaning:
MAOs must follow NCDs and CEDs exactly as written
No modifications, supplements, or internal policies may override them
Non-compliance may result in CMS enforcement actions
4. 2027 Medicare Drug Price Negotiation Program
CMS has published the Maximum Fair Prices (MFPs) for 15 high-cost Part D drugs selected for the 2027 negotiation cycle. These prices are effective January 1, 2027 and were negotiated between CMS and manufacturers. The drugs include those without generic or biosimilar competition. The files are available in both .csv and .xlsx formats.
Conversely, Entresto, Stelara, and Xarelto will be removed from the selected drug list starting in 2027, as each now has a generic or biosimilar alternative.
5. Part C 2025 Reporting: Technical Document Updates
CMS released updates to Part C 2025 reporting requirements, including changes to:
D-SNP Enrollee Advisory Committees
Transmission of Admission Notifications (TAN)
Payment to Providers
Organization Determinations & Reconsiderations
Revised record layouts and edit rules are now posted in HPMS.
6. Data Validation Review Results for CY 2024
The CY 2024 data validation audit (April–June 2025) covered 746 contracts. Results showed exceptionally high compliance, with validation scores averaging above 98.75% across categories.
7. 2026 Utilization Management (UM) Data Submission
The HPMS UM Module is now live for 2026 data submissions. MAOs must report all Internal Coverage Criteria (ICC) used in prior authorizations by April 30, 2026.
8. December 2025 MARx Payment Updates
The December Medicare Advantage/Part D (MARx) payments will reflect:
2025 Manufacturer Discount Program (MDP) invoice offsets
Ongoing sequestration adjustments
Payment troubleshooting support through CMS’s MAPD Help Desk
9. Medicaid.gov Notices
A series of OMB Review notices have been published for comment on Medicaid and Medicare programs. Stakeholders should monitor the Federal Regiserfor submission deadlines.
Conclusion:
These updates underscore CMS’s continued focus on transparency, data integrity, and program modernization. MAOs and PDPs should take immediate steps to ensure compliance with the revised reporting standards, drug pricing rules, and utilization management submissions.
