What Medicare Advantage Organizations need to know about the CMS data model changes for AEP 2026

Every Spring, the Centers for Medicare & Medicaid Services (CMS) releases updates to the PBP data used for the generation of the Annual Notice of Change (ANOC) and the Evidence of Coverage (EOC) model documents.

The ANOC and EOC play a critical role in helping plan members understand plan offerings by providing a detailed summary of benefits, cost-sharing details, and any modifications to coverage. The CMS model documents define both the layout and content guidelines that Medicare Advantage Organizations (MAOs) must follow when preparing these member materials. To comply with CMS requirements, MAOs must ensure that all beneficiaries receive accurate, up-to-date ANOC and EOC documents in advance of the Annual Enrollment Period (AEP), which runs from October 15 to December 7. This ensures members have enough time to make informed decisions about their coverage for the upcoming year.

For AEP 2026, CMS has introduced a series of changes to the Plan Benefit Package (PBP) data model. These updates introduce new model language for benefit distinctions, removal of obsolete offerings, and refined cost-sharing structures for certain benefits. Here’s a breakdown of the key changes introduced for the 2026 AEP, their impact on Medicare Advantage communications, along with practical guidance for how MAOs can incorporate them into their plan materials:

1.      Partial Hospitalization (5)

Service Category 5 has been refined into two distinct categories:

• 5a: Partial Hospitalization
• 5b: Intensive Outpatient Program Services

This change aligns with CMS’s broader goal of enhancing delivery of care by more precisely categorizing services based on intensity levels within outpatient care. The split of Service Category 5 into Partial Hospitalization (5a) and Intensive Outpatient Program Services (5b) must be clearly communicated in the ANOC to ensure beneficiaries clearly understand this change in treatment categorization. The change would also need to be described appropriately for the members in EOC and SB communications.

2.      Blood Three (3) Pint Deductible Waived (9d)

The 9d Benefit Offering has been removed and replaced with a new question under Benefit Details 9d. The removal of this benefit offering simplifies the CMS Data Model but may raise questions among beneficiaries accustomed to this coverage.

With the removal of the “Blood Three Pint Deductible Waived (9d)” benefit offering and its replacement with a new question under Benefit Details 9d, MAOs will need to adjust how this information is captured in their PBP data to ensure their ANOCs and other Medicare Advantage communications accurately reflect the updated benefit structure.

3.      Removal of Barium Enemas (14e3)

Barium Enemas (14e3) have been removed from the list of Medicare-covered benefits starting in CY2026, as the procedure is rarely used and no longer recommended as an evidence-based screening method. MAOs will need to highlight this removal in the ANOC to ensure beneficiaries are aware of the change in covered services, and describe it appropriately in the EOC and SB documents.

4.      OTC Items – Mode of Delivery (13b)

New response options have been introduced for over-the-counter (OTC) items, expanding delivery methods to include:

• Catalog Purchase
• Claims Processing
• Debit Card Reimbursement

The addition of these new delivery methods enhances flexibility for beneficiaries and supports greater user choice in how OTC items are accessed. These changes will require updates in the respective EOC sections explaining the delivery methods. This information will also need to be provided in the ANOC to ensure members are aware of the updates to their OTC benefits.

5.      PPO OON Cost Share Removal

Group cost share groupings for PPO Out-of-Network (OON) services have been removed and integrated directly into Benefit Details, streamlining benefit processing and eliminating redundancies. MAOs will need to adjust how this benefit is captured in their PBP data to ensure updates are accurately reflected across all Medicare Advantage materials.

6.      VBID Model Discontinuation

The Value-Based Insurance Design (VBID) Model has been removed for CY2026, representing a notable policy shift for the upcoming plan year. MAOs will need to clearly outline the removal of VBID in their plan documents to ensure beneficiaries understand its discontinuation and how it impacts their coverage.

7.      Supplemental Benefits for the Chronically Ill (SSBCI) / Uniformity Flexibility

Further updates bring flexibility and expand coverage options:

• Chronic Conditions: The list of diseases eligible for benefits under the SSBCI has been updated.
• General Support for Living: New SSBCI questions have been added, addressing rent/mortgage and utility coverage for individuals needing assistance.

Updates to chronic condition eligibility under SSBCI will require changes across all plan materials, including the SB, to outline the updated list of diseases.

New SSBCI questions related to rent, mortgage, and utility support must be incorporated into the EOC and other plan documents to ensure clarity for eligible beneficiaries.

8.      Rx Insulin Changes

Changes to insulin coverage introduce a cap of the lesser of $35, 25% of the negotiated price, or 25% of the Maximum Fair Price (MFP). This adjustment is aimed at improving affordability and accessibility for beneficiaries. MAOs must ensure these changes are clearly described in the ANOC, EOC, and Summary of Benefits (SB) documents, to ensure Part-D cost-sharing details are accurately explained.

A Smarter Way to Handle CMS Changes

Compared with previous years, the CMS changes for AEP 2026 are limited in scope, but MAOs relying on manual processes or legacy document generation systems will still find it complex, resource-intensive, and time-consuming to incorporate them into their plan materials.

For MAOs using the Messagepoint Healthcare Touchpoint Exchange, a cloud-based platform purpose-built to streamline the creation and management of Medicare Advantage communications, the application of updates across materials is automated. Each year, the latest CMS model content and layout are automatically incorporated across their ANOC, EOC, and SB documents in both English and Spanish, giving teams a pre-built starting point before their AEP preparation even begins.

Messagepoint’s content-centric approach enables common content components to be shared and reused across multiple documents while being centrally controlled from a single point of change. This enables MAOs to easily apply any CMS changes. Even if CMS issues a memo just weeks before the deadline (as they did last summer), teams only need to update the affected benefit description or cost-sharing chart once, and the change is automatically reflected across all impacted documents, eliminating the need to revise each one manually. When combined with integrated QA tools, automated 508 compliance, and AI-powered translation and accuracy checks, Messagepoint customers reduce their workloads by up to 70% after switching from legacy solutions.

The nature and scope of CMS updates may be unpredictable, but with Messagepoint, you can ensure your team is prepared.

Download “Top 20 Questions to Ask When Vetting a Document Management Solution for Medicare Plan Materials” to evaluate whether your current document generation solution is equipped to handle changes like those coming in AEP 2026.