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CMS Confirms Risk Adjustment Deadlines, Appeals Protocols & CY 2026 Bid Guidance (Week of 4/28/25–5/2/25)

Beacon Alert 2025-018 Weekly Regulatory Updates

In this week’s regulatory roundup, CMS delivered a wide array of critical updates affecting Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), PACE organizations, and Medicare-Medicaid plans. From finalized risk adjustment data submission schedules to crosswalk exceptions, this Beacon Alert provides strategic guidance for compliance, finance, and bidding teams as they prepare for Contract Years 2025–2027.

Risk Adjustment Data Submission Deadlines Confirmed Through 2027

CMS clarified the data submission timelines for RAPS and EDS systems, which will impact how risk scores are calculated for upcoming payment years. Each run—Initial, Mid-Year, and Final—has its own submission deadline and associated payment cycle.

📌 Key Submission Deadlines:

  • 2026 Initial Run
    Dates of Service: 07/01/2024 – 06/30/2025
    Deadline: September 5, 2025
    Payment: January 2026

  • 2025 Final Run
    Dates of Service: Full CY 2024
    Deadline: February 2, 2026

  • 2026 Mid-Year Run
    Dates of Service: Full CY 2025
    Deadline: March 6, 2026

  • 2027 Initial Run
    Dates of Service: 07/01/2025 – 06/30/2026
    Deadline: September 4, 2026
    Payment: January 2027

⛔ Reminder: No data submitted after the final deadline will be included in any risk score run. CMS will only process deletes after that point.

Part D: Manufacturer Discount Lists Corrected for May 2025

CMS issued a corrected Participating Labeler Code List and Phase-In NDC List for the Medicare Part D Manufacturer Discount Program. These replace versions from April 23, 2025.

📧 Questions? Email:
PartDManufacturerDiscountProgram@cms.hhs.gov

2026 Crosswalk Exception Submission Window

Plan sponsors must submit crosswalk exceptions in HPMS between June 3–4, 2025.

  • Who Must Act: MAOs, PDPs, MMPs, Section 1876 Cost Plans

  • Key Regulation References:

    • 42 CFR §§ 417.496, 422.530, 423.530

    • Chapter 5 of the Bid Submission Manual

📝 All crosswalk verifications must be completed in HPMS by July. Without verification, contract approvals will be denied.

May 2025 Payments: CPT/HCPCS Update for 2015 Risk Adjustment Rerun

The May 1, 2025 payment includes a PY 2015 risk adjustment reconciliation rerun based on the reinstatement of the 2012 CPT/HCPCS exclusion list for FFS claims from service year 2014.

Bid Submission Open for CY 2026

The HPMS CY 2026 bid submission module is now live. All materials must be submitted by:

  • Bid Submission Deadline: June 2, 2025 (11:59 PM PDT)

  • Supplemental Formulary Files (if applicable): June 6, 2025 (11:59 AM EDT)

📌 New Crosswalk Policy for PDPs: Consolidated renewals must go through the Crosswalk Exception window.

New Guidance for MA RADV Level II Appeals

MA organizations may file a Level II appeal through the CMS Office of Hearings Case and Document Management System (OH CDMS) following a Level I denial.

🧭 Access procedures and user manuals:
CMS Hearing Officer RADV Appeals Info

Encounter Data Report Cards: Q1 2025 Now Available

MAOs can access Q1 2025 Encounter Data Report Cards in HPMS:
📂 Risk Adjustment > Encounter Data Report > 2025 May Update

📧 Contact:
RiskAdjustmentOperations@cms.hhs.gov
Subject: “Report Card Q1 2025 Update”

Additional Modules

Todd Petersen,

Chief Executive Officer & Board Member

Todd brings 22 years of experience in scaling SaaS-based companies within the health plan payer market. He has a proven track record of fostering strong client relationships and building high-performing teams. Todd joined Beacon Healthcare Systems from HighRoads, where he played a pivotal role in providing SaaS solutions for health plan design and modification. His extensive career includes significant contributions to sales and growth at HealthSparq, a web-based consumer enablement solution provider; InstaMed, which facilitates financial transactions among payers, members, and providers; DestinationRx, specializing in Medicare shopping for government and commercial programs; and Ingenix, known for its cost containment technology services. Todd is also an acting board member for Beacon Healthcare Systems.

Jeremy Hays

Vice President of Strategic Accounts

Jeremy is an accomplished executive with extensive experience in health insurance and supporting technology. He is a seasoned sales and operational leader passionate about driving revenue growth and elevating customer satisfaction He has a long track record in Medicare leading teams to consistently exceed revenue targets by developing and executing highly effective growth strategies within organizations like United Healthcare, DestinationRx, and InstaMed, all while nurturing enduring, mutually beneficial customer relationships. Jeremy will be leading the existing Account Management team.

Alexis Elam JD, CHC

Vice President of Compliance

Alexis is a trusted and valued healthcare compliance, privacy, and risk leader with 18+ years of audit, oversight, and effective program management across payors, providers, and SaaS support tools. She specializes in implementing corporate initiatives and software solutions that promote adherence to government contracting and service delivery regulations.

Chris Mahoney

Chief Financial Officer

Chris Mahoney is a resourceful and results-driven senior finance executive with 25+ years of CFO-level experience leveraging keen financial expertise to create cost-efficient and sustainable financial results across both small and large corporate organizations. He consistently demonstrates the ability to critically evaluate and respond to rapidly evolving environments while identifying business-critical financial enhancements and developing proactive and actionable improvement initiatives.
Chris also utilizes business acumen and cross-functional communication skills to routinely produce sophisticated solutions and align all financial activities with strategic business goals. Chris has acquired and integrated businesses, assisted in raising millions in $30mm equity and debt through private placements, transformed a business from a Perpetual to a SaaS model, assisted in growing businesses from $250mm to $1bn, and has implemented Project Accounting systems, cost, and management information systems.

Ken Stockman

Chief Executive Officer
Ken Stockman, Founder and Chief Executive Officer of Beacon Healthcare Systems, is a seasoned healthcare executive with strong Payer and Provider experience focused on bringing innovative solutions to Government program revenue management, operations, compliance, and risk adjustment. Ken was an early leader in the Medicare Advantage Risk Adjustment industry building a full suite of tools such as Full Enrollment, Member Reconciliation And Part D Platform to support the health plans’ initiatives in 2006 as co-founder and former CEO of Dynamic Healthcare Systems, Inc. His expertise in Risk Adjustment Strategy, Transaction Processing And Analytics positions him as a unique subject matter expert. Additionally, his experience in CMS Transaction Processing And Regulatory Requirements led to the successful design and implementation of industry-leading information systems.