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The resulting impact was an average increase in the standardized FFS costs in Puerto Rico of 4.1 percent for 2019 through 2023. Accordingly, a 4.1 percent adjustment was applied to the pre- standardized Puerto Rico FFS rates supporting the CY 2026 ratebook development. For future years, CMS plans to continue to evaluate the methodology for calculating rates for Puerto Rico plans to ensure the rates are based on the best estimates of Medicare FFS per capita costs in Puerto Rico and reassess the need for ongoing special adjustments. Section E. Direct Graduate Medical Education Maryland TCOC Model See Comments and Responses in the section titled “Organ Acquisition Costs for Kidney Transplants.” Section F. Organ Acquisition Costs for Kidney Transplants Maryland TCOC Model Note: On March 12, 2025, CMS announced an earlier termination schedule for several Innovation Center models. CMS aims to conclude the Maryland Total Cost of Care, Primary Care First, ESRD Treatment Choices, and Making Care Primary models by December 31, 2025. The geographic adjustments for the five year historical experience period (2019-2023) used for CY 2026 ratebook development are unaffected by the earlier model terminations. Given the time constraints of the statutory announcement of the CY 2026 MA rates and the timing of the model termination announcement, we have not assessed whether the earlier model terminations would impact the assumptions used for USPCC projections for 2026 and thereafter. As such, we expect that any impacts on USPCC assumptions will be first incorporated in the CY 2027 Advance Notice. Comment: Commenters expressed concerns with the Maryland TCOC Model DGME, IME, and KAC carve-outs, stating that the proposed KAC methodology will create added challenges for Maryland MA organizations already facing a suboptimal MA market. Commenters stated that sustaining the adjustment methodology for DGME and IME, as finalized in the CY 2025 Rate Announcement, and proceeding with the proposed KAC adjustment will continue to cause rate reductions for Maryland counties. A few commenters discussed the unique challenges faced by Maryland MA plans due to the interactions between the MA benchmark methodology and the Maryland TCOC Model, emphasizing the need to ensure that payment policies adequately reflect the expected costs of providing covered services. Commenters highlighted that the adjustments particularly impact Baltimore City and Baltimore County, which have a higher-than-average number of low-income beneficiaries and individuals facing disparities in care and social risk factors related to income, education, and health status. Commenters indicated that for CY 2026, 22 out of Maryland’s 24 counties are in the 95 percent