As we look ahead to 2026, significant changes to Medicare Advantage (MA) and Part D payment and risk models are set to impact clinics, providers, and plan partnerships. While these adjustments are often discussed at the plan level, they can directly influence how your clinic is evaluated, reimbursed, and positioned in value-based arrangements.
Understanding these changes now—and taking proactive steps—can ensure your clinic is ready to navigate the new landscape successfully.
What’s Changing in 2026
CMS has announced several key updates for CY 2026 that clinics should be aware of:
- Payment adjustments: Medicare Advantage plans are projected to see an average payment increase of 5.06% from 2025 to 2026.
- Risk model shifts: The 2024 CMS-HCC model will be fully implemented for MA in 2026, with revised normalization factors affecting how risk scores are calculated.
- Part D updates: Changes to the Part D risk adjustment model (RxHCC) now reflect negotiated drug prices under the Inflation Reduction Act of 2022 and updated out-of-pocket caps.
- ACO/REACH modifications: The Coding Intensity Factor ceiling for high-needs ACOs is increasing, the Quality Withhold is rising from 2% to 5%, risk corridors are narrowing, and the regional benchmark weight is decreasing.
Together, these changes affect how plans calculate risk, distribute payments, and evaluate network performance—all of which can have downstream effects on clinic contracts and provider reimbursement.
Why Clinics Need to Pay Attention
Even if your clinic does not directly contract as an MA plan, your participation in value-based contracts, ACOs, or plan partnerships means these payment and risk updates matter. Clinics that are proactive about documentation accuracy, coding compliance, and patient complexity capture will:
- Demonstrate their value to plan partners.
- Reduce the risk of payment adjustments or audit findings.
- Strengthen their position in contract negotiations.
Simply put, these updates are not just plan-level issues—they are an opportunity for clinics to show readiness, accuracy, and value.
Practical Steps for Clinics
To position your clinic for success under the 2026 payment and risk landscape, consider these actionable steps:
- Review contracts with MA/ACO partners: Understand how risk coding and encounter data influence payment and performance evaluation.
- Align workflows and documentation: Ensure that clinical documentation accurately reflects chronic conditions and comorbidities that impact risk adjustment.
- Educate providers and coding staff: Focus training on conditions that disproportionately affect risk scores, and ensure consistent capture in the EHR.
- Monitor and benchmark performance: Establish baseline coding accuracy and risk-score capture metrics, then track improvements over time.
Proactive attention to these areas not only reduces compliance risk but also positions your clinic to optimize revenue and strengthen plan partnerships.
Take the Next Step with BCA
Navigating 2026 payment and risk model changes doesn’t have to be overwhelming. BCA specializes in helping clinics align documentation, coding, and workflows with evolving Medicare Advantage and Part D requirements.
We partner with clinics to:
- Audit coding and documentation for accuracy and risk-adjustment readiness.
- Train providers and staff on capturing patient complexity.
- Implement workflow improvements that support both compliance and operational efficiency.
Ready to position your clinic for success in 2026? Contact BCA today to assess your readiness and build a roadmap to optimize your partnerships, maximize revenue, and ensure your clinic is prepared for the year ahead.