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As noted on page 30 of the CY 2026 Advance Notice, CMS released the 2023 FFS cost data by county used in the development of the CY 2026 ratebook. The data is published on the CMS website at https://www.cms.gov/medicare/payment/medicare-advantage-rates-statistics. With the Rate Announcement, CMS annually publishes a tool and corresponding glossary, Medicare FFS County 20YY web.xlsm, which provides stakeholders with means to replicate the FFS rate development, and publishes information regarding county-level geographic indices and repricing adjustments. Using this information, stakeholders are able to analyze the drivers of changes in FFS per capita costs for specific counties from one ratebook to another. CMS appreciates the concerns raised regarding potential impacts of wage index changes on hospital rural reclassification. Puerto Rico Comment: Commenters supported continuing the adjustment of the calculation of benchmarks in Puerto Rico using only claims data for beneficiaries enrolled in both Parts A and B, the adjustment to the FFS experience for beneficiaries enrolled in Puerto Rico to reflect the nationwide propensity of beneficiaries with zero claims, and expanded eligibility for double bonuses. A commenter stated that these adjustments remain necessary to help plans in Puerto Rico maintain benefits for the low-income populations they serve. Some commenters also stated that these adjustments produce a more accurate projection of FFS costs per capita in Puerto Rico. However, stakeholders also recommended a number of additional proposals for calculating MA rates in Puerto Rico. Many commenters stated that they are concerned about the large disparity in payment rates between Puerto Rico and the U.S. mainland and requested additional increases to the Puerto Rico rates. Several commenters observed that MA rates in Puerto Rico are 39% lower than the national average and 21% lower than the MA rates in the U.S. Virgin Islands (USVI) due to differences in Medicare payment formulas, population, economic factors, and data sources. A commenter further asserted that payment in Puerto Rico does not adequately cover the costs of providing care in Puerto Rico relative to the U.S. mainland and could jeopardize MA plans’ ability to provide services in Puerto Rico. One commenter asserted that, despite these disparities, Puerto Rico consistently outperforms the rest of the nation in health care quality outcomes. Commenters requested that CMS make additional and continuous adjustments to MA payments in Puerto Rico to account for these dynamics and to achieve greater parity with FFS rates on the mainland. Some commenters supported the use of a proxy as a method to control payment rates. Commenters specifically recommended applying the AGA from a comparable geography, such as the USVI. Other commenters specifically asked CMS to establish a minimum AGA of 0.7 either as a national MA benchmark floor or specifically for Puerto Rico. Commenters recommended a minimum AGA of 0.7 because it would be a level similar to the current 0.70 AGA factor of the USVI. A few commenters suggested that CMS tether Puerto Rico rates to the national average AGA. Some commenters also recommended that CMS make an adjustment to