November 2026 MARx Payment Update: What Medicare Advantage Plans Need to Know
CMS MARx PAYMENT UPDATE | OCTOBER 29, 2026
In This Article
1. CMS Update at a Glance - October 29, 2026
The Centers for Medicare & Medicaid Services (CMS) issued its October 29, 2026, Medicare Advantage/Prescription Drug System (MARx) November 2026 Payment – INFORMATION memo to Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost Plans, PACE organizations, and demonstrations.
The memo covers more than the upcoming payment date. It also addresses a Part D reconciliation adjustment, the reporting schedule for updated MAO-004 risk adjustment reports, ongoing sequestration, and how plans should handle MAPD Help Desk tickets involving premium or payment information.
November 2026 at a Glance
Three important updates from the October 29 CMS MARx payment memo.
November MA and Part D Payment
November 2026 payments are scheduled for receipt by plans.
October 30, 20262025 Final Reconciliation
The adjustment is included in the November payment and appears as PRS under Special CMS Adjustments on the PPR.
Adjustment type: PRSPhase 4.1 Timeline Update
Phase 4.0 reports continue in November and December. Phase 4.1 reports will be reissued after an HPMS notice.
Further CMS guidance pending2. Understanding the 2025 Part D Reconciliation Adjustment
The October 29, 2026, memo confirms that the 2025 Final Part D Payment Reconciliation adjustment is included in the November 2026 payment. CMS specifies that the adjustment will appear on the Plan Payment Report (PPR) under Special CMS Adjustments, with the type of PRS. For plan teams reviewing monthly payment information, recognizing this code is important. It helps distinguish the reconciliation adjustment from other payment items recorded in the report.
Finding the PRS Adjustment
What Plans Should Do: Review the November payment reconciliation adjustment on the PPR and identify the PRS entry. Reconcile it with the plan's internal payment records and applicable Part D reconciliation documentation.
3. MAO-004 Phase 4.0 and Phase 4.1: What Happens Next?
One of the most important operational updates in the October 29, 2026, memo concerns the release schedule for the MAO-004 Phase 4.1 reports.
CMS is updating the Phase 4.1 report to reflect the diagnosis exclusions associated with the CY2027 risk adjustment policies. However, the release timeline has changed. Instead of moving directly to the updated reports, CMS will continue issuing Phase 4.0 reports for the next two reporting cycles.
3.1 The Revised Reporting Timeline for Phase 4.0 versus Phase 4.1
Phase 4.0 Report
Reports for October submissions will continue under the Initial model run.
Phase 4.0 continuesPhase 4.0 Report
Reports for November submissions will continue under the Initial model run.
Phase 4.0 continuesPhase 4.1 Reports
CMS will issue an HPMS notice before reissuing the Phase 4.1 reports.
The updated reports will reflect diagnosis exclusions consistent with the CY2027 Midyear model run. Additional information, including the Phase 4.1 MAO-004 User Guide, will be provided before release.
Awaiting CMS notice3.2 Why Does This Distinction Matter?
The difference is not simply a change in the report version. The two phases are associated with different risk score calculations. The continued Phase 4.0 reports are consistent with the Initial model run. The later Phase 4.1 reports will reflect the diagnosis exclusions consistent with the CY2027 Midyear model run. This means plans should not treat the continued Phase 4.0 releases as confirmation that the updated Phase 4.1 reporting changes have already been applied.
What Plans Should Watch For: CMS has stated that it will issue an HPMS notice before the reissued Phase 4.1 reports are released. Plans should monitor that communication and review the updated User Guide when it becomes available.
4. What the CY2027 Diagnosis Exclusions Mean
To understand why CMS is updating the MAO-004 report, it helps to look at the CY2027 risk adjustment policies behind the change.
The October 29, 2026, memo identifies two areas addressed in the updated Phase 4.1 reporting:
Diagnoses from unlinked Chart Review Records (CRRs).
Diagnoses from audio-only encounters.
These changes reflect policies finalized in the CY2027 Medicare Advantage and Part D Rate Announcement.
4.1 Unlinked Chart Review Records
A Chart Review Record (CRR) is used to submit diagnosis information identified through a review of a beneficiary's medical record.
An unlinked Chart Review Record (CRR) is not associated with a specific beneficiary encounter. The CY2027 policy addresses whether diagnoses submitted through these records are included in risk score calculations. The Rate Announcement finalizes the exclusion of diagnoses from unlinked Chart Review Records (CRRs), with an exception for beneficiaries who switch from one MA organization to another.
Why It Matters: A diagnosis appearing in a submitted record does not automatically mean it will be included in the risk score calculation. The applicable record type, policy rules, and exceptions matter.
4.2 Audio-Only Encounters
The CY2027 Rate Announcement also finalizes the exclusion of diagnoses from audio-only encounters from risk score calculations.
Audio-only encounters involve healthcare services delivered through audio communication without a video component. The policy addresses the use of diagnoses from these encounters in risk adjustment.
Why It Matters: Plans should understand that the presence of a diagnosis in submitted data and its eligibility for risk score calculation are separate considerations.
Understanding the Policy and the Report Update
How Diagnosis Information Is Considered
The CY2027 policies identify diagnosis information that is excluded from risk score calculations, subject to applicable exceptions.
Diagnosis Information
Information from encounter data and chart review records.
Apply CY2027 Policy Rules
Consider the record type, encounter type and applicable policy exceptions.
Potentially Eligible
Diagnosis information that meets applicable risk adjustment requirements and exceptions may be considered.
Excluded from Risk Scores
Diagnoses from audio-only encounters and unlinked chart review records are excluded, subject to applicable exceptions.
4.3 What About PACE Organizations and Beneficiaries Who Change Plans?
The exceptions deserve particular attention. The October 29, 2026, memo identifies PACE organizations and beneficiaries who switch from one parent organization to another in its description of the Phase 4.1 report updates.
The CY2027 Rate Announcement also explains a specific exception for unlinked Chart Review Records (CRRs) submitted for beneficiaries who switch from one MA organization to another. Separately, it finalizes a transition approach for PACE organizations: CY2027 PACE risk scores will blend 50% of the score calculated using the 2024 MA risk adjustment model and 50% using the 2017 MA model.
These are related but distinct policy details. Plans should refer to the full Rate Announcement and the forthcoming Phase 4.1 User Guide for the applicable treatment of their records and circumstances.
For a deeper look at risk adjustment, diagnosis documentation, and coding considerations, see Health Data Max's Risk Adjustment Models & Coding Precision resources.
5. What the Policy Means for Encounter Data Submissions
Medicare Advantage risk adjustment relies on diagnosis information submitted to CMS through established data submission processes. Encounter Data Records (EDRs) and Chart Review Records (CRRs) are important components of this process.
The MAO-004 report provides Medicare Advantage organizations with reporting on diagnoses from encounter data and chart review records. However, the presence of a diagnosis in a submitted record does not automatically mean it will be included in a risk score calculation. Under the CY2027 policies, diagnoses from certain unlinked chart review records and audio-only encounters are subject to exclusion, with applicable exceptions.
Plans should review the applicable CMS guidance and the forthcoming Phase 4.1 MAO-004 User Guide to understand how these changes are reflected in their reports.
Encounter Data Records (EDRs) & Chart Review Records (CRRs)
Plans submit encounter data and chart review records to CMS.
CMS Processing
CMS processes submitted records under applicable requirements.
MAO-004 Report
The report provides information about diagnoses from encounter data and chart review records.
Risk Adjustment Diagnosis Eligibility
Diagnosis eligibility is determined under applicable CY2027 policies and exclusions.
Conceptual illustration of the relationship between encounter data, MAO-004 reporting, and risk adjustment diagnosis eligibility.
6. A Practical Checklist for Medicare Plans
As CMS prepares to issue the updated Phase 4.1 MAO-004 reports, Medicare Advantage organizations should:
Review the revised Phase 4.1 reporting timeline and watch for the CMS HPMS notification.
Continue monitoring Phase 4.0 reports scheduled for November and December.
Review how unlinked CRRs and audio-only encounter diagnoses are treated under CY2027 risk adjustment policies.
Pay attention to the applicable exceptions for PACE organizations and beneficiaries who switch between organizations.
Review the forthcoming Phase 4.1 MAO-004 User Guide when CMS releases it.
6.1 The Three Things to Prioritize
If teams take only three points from this update, they should be:
Review the November PPR: Identify the 2025 Final Part D reconciliation adjustment under type PRS.
Prepare for the MAO-004 reporting sequence: Phase 4.0 reports continue in November and December; monitor CMS communications for the later Phase 4.1 reissue.
Keep the CY2027 policy changes in view: Understand the diagnosis exclusions and exceptions, and make sure the teams responsible for risk adjustment reporting are aware of them.
7. Final Takeaway
The October 29, 2026, MARx memo is an important operational update for Medicare Advantage and prescription drug plans. It confirms the November payment date, identifies the 2025 Part D reconciliation adjustment, and clarifies the reporting sequence for the MAO-004 Phase 4.1 updates.
For plans, the immediate priority is to review the November payment reconciliation adjustment on the PPR and identify the PRS adjustment. At the same time, risk adjustment and reporting teams should prepare for the continued Phase 4.0 releases and monitor CMS communications for the updated Phase 4.1 reports.
Understanding these details can help payment, finance, and risk adjustment teams stay aligned as CMS moves through the CY2027 reporting and payment cycle.
8. Official CMS Resources
CMS Memorandum: November 2026 MARx Payment – October 29, 2026
Original CMS memorandum covering the November 2026 payment and related updates.
Add the original memo PDF or HPMS link here.CY2027 Medicare Advantage and Part D Rate Announcement – CMS
Supporting policy information on the finalized CY2027 risk adjustment changes.2027 Rate Announcement – Full CMS Document
Full details of the finalized CY2027 Medicare Advantage and Part D payment policies.
9. Questions?
For questions about the November 2026 MARx payment, payment adjustments, or information in the October 29 memorandum, contact the CMS MAPD Help Desk.
Email: mapdhelp@cms.hhs.gov
Phone: 1-800-927-8069
If your organization has already submitted a trouble ticket regarding a premium or payment issue, no further action is required. If your ticket has been consolidated under a parent ticket, CMS is aware of the issue and is working to assess and address it.
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