ACO REACH SDoH reporting carries more financial weight in the model’s final performance year than in any year before it.
The quality withhold rises to 5% of the benchmark under the CMS ACO REACH PY2026 Model Update Quick Reference, so incomplete reporting now leaves a measurable share of an ACO’s earn-back unrealized. The collection deadline is December 31, 2026. The calendar is the one stakeholder that will not take a meeting, and it leaves little room for records to sit idle between practices, inboxes, and half-finished spreadsheets.
The Centers for Medicare & Medicaid Services (CMS) now calls this reporting data Upstream Drivers of Health (UDOH) in its ACO REACH Model materials. For ACO leaders, the task is to find unresolved records, complete eligible collection and documentation within the performance year, and assemble a dataset that holds up under submission review.
Mabel’s PY2025 SDoH case study shows what that work looks like at scale. Beneficiary notices need attention alongside it. If your ACO is behind on its PY2026 screenings, talk to Mabel about closing your reporting gaps before December 31.
What SDoH Reporting Is Worth in PY2026
The CMS ACO REACH PY2026 Model Update Quick Reference raises the quality withhold from 2% to 5% of the financial benchmark. That makes the quality score used to determine earn-back more consequential.
Under the PY2026 quality methodology, UDOH reporting can add up to five percentage points to the total quality score through the Data Reporting adjustment. Demographic reporting no longer contributes to that adjustment.
For an ACO with a $100 million benchmark, the reporting contribution looks like this:
| UDOH reporting rate | Data Reporting adjustment | Reporting contribution to quality-withhold earn-back |
| 40% | 2 percentage points | $100,000 |
| 60% | 3 percentage points | $150,000 |
| 95% | 4.75 percentage points | $237,500 |
| 100% | 5 percentage points | $250,000 |
These figures assume the ACO has enough room below the 100% quality-score cap. They isolate the reporting adjustment’s effect on quality-withhold earn-back before service costs. They are not a forecast of total shared savings.
Moving from 40% to 95% reporting is worth $137,500 in this example. One missing record looks trivial on its own, but across a full reporting population, those gaps can compound to create a significant financial shortfall.
If your ACO has unresolved records, talk to Mabel about completing your year-end reporting work before the collection window closes.
How the Adjustment Fits the Quality Calculation
CMS applies the Data Reporting adjustment after the Continuous Improvement/Sustained Exceptional Performance (CI/SEP) multiplier. An ACO that misses the CI/SEP criteria has its initial quality score multiplied by 0.8, but that multiplier does not reduce the reporting adjustment. ACOs with weaker results elsewhere still have a concrete reason to finish the reporting work.
The Data Reporting adjustment is also distinct from the PY2026 Population Adjustment. The two mechanisms answer different questions, and finance should model them separately.
What Makes a Record Reportable
A survey sent, a response received, and a record ready for submission are different milestones. The reporting process needs to account for each.
CMS supplies the reporting population through a prepopulated roster. Reconcile practice records against that roster rather than adding or removing beneficiaries to match an internal patient list.
The approved screening instruments are the AHC Health-Related Social Needs Screening Tool, the North Carolina SDOH Screening Tool, and PRAPARE. Different practices may use different approved instruments, but a beneficiary’s submitted responses must come from one instrument.
Preserve the Evidence Behind Each Status
Keep the beneficiary identifier, screening instrument, collection date, response values, and outreach history connected. A central reviewer should be able to trace a submitted record back to its source without reconstructing the story from several systems.
Document outreach attempts and beneficiary responses as they occur. Apply the current CMS implementation guide’s instructions when coding declines or nonresponse, retaining the evidence required for each status.
This distinction matters: reporting coverage and completed-screening response rates measure different things. Campaign reports should name the measure they describe.
Keep Collection and Submission Separate
PY2026 collection must occur within the performance year. A later submission window gives teams time to prepare and correct the file; it does not extend the period for collecting qualifying data.
January can provide time to repair a submission. It cannot supply a December collection date that was never recorded.
How to Close Reporting Gaps Before December 31
Reconcile Before Sending More Outreach
Bring together records from every participating practice and match them against the CMS roster. Identify completed screenings, documented outreach outcomes, incomplete records, and beneficiaries still requiring attention.
A screening may already exist in a practice’s electronic health record while appearing missing in the ACO’s central tracker. Reconciliation helps prevent duplicate requests and gives leadership a more accurate account of the remaining workload.
Give Each Practice a Clear Handoff
Assign a contact at each practice and define what the central team needs, when it is due, and who will resolve exceptions.
One practice may send structured exports while another relies on paper forms. Test each handoff early enough to uncover missing identifiers, unclear response values, or instrument-mapping problems.
A completed screening has little reporting value if it remains stranded in the system that collected it.
Coordinate Outreach Across Channels
Use direct mail, email, and in-clinic collection according to your campaign design and beneficiary contact preferences. Reconcile incoming records before each new outreach round so patients do not receive repeated requests after their records have been resolved.
Track the date and outcome of each attempt. Where responses identify social needs, connect the information to the appropriate care team through the ACO’s existing follow-up process.
Validate While There Is Time to Correct
Review identifiers, required fields, collection dates, and instrument consistency throughout the campaign. Assign an owner to unresolved exceptions and review progress by practice.
Waiting until January to discover a recurring collection problem leaves fewer ways to solve it. Regular validation gives practices time to correct the process while eligible collection is still possible.
Prepare Beneficiary Notices Alongside Reporting
The final year of REACH brings two calendars into view: the work required to close the model and the communications needed for the transition. They compete for many of the same staff and resources.
Plan the REACH Expiration Notice
The closeout schedule cited in the October participant materials calls for written notice of the model’s expiration by November 30, 2026, with CMS review before distribution.
Build the schedule backward from mailing. Finalize the beneficiary list, prepare the notice for review through the applicable 4Innovation process, and reserve production capacity. Use the latest CMS closeout instructions to confirm the approval timetable and required language.
An approval process needs room for revisions. Printing and mailing need room of their own.
Coordinate Communications for the LEAD Transition
For organizations preparing for LEAD participation, transition communications should sit alongside REACH closeout notices in one coordinated plan.
Confirm the latest CMS requirements for carryover and LEAD beneficiary notices before finalizing language or distribution dates. Segment lists by the communication each beneficiary needs and prepare staff to answer questions consistently.
To an ACO, these may be separate compliance tasks. To a beneficiary, they arrive in the same mailbox. Clear language and coordinated timing can help make the transition understandable.
How Mabel Supports the Final-Year Work
Mabel’s PY2025 SDoH case study reports support for 35 ACO REACH organizations, more than 95% reporting, and returns on investment ranging from 6x to 19x.
The work combined direct-to-patient and in-clinic collection, aggregation across electronic health record formats, and tracking by provider and patient. That approach gives ACO teams a consolidated view of the reporting population and the records still requiring attention.
Mabel also supports beneficiary notification campaigns, helping organizations coordinate the operational work behind required communications.
The immediate priority is to establish what remains unfinished and give each item a path to completion. December 31 will close the collection window whether the records are ready or not.
Contact Mabel to plan your remaining SDoH reporting work and year-end beneficiary notices.
Frequently Asked Questions
When does PY2026 SDoH data collection end?
PY2026 SDoH collection ends on December 31, 2026. Submission and correction activities continue afterward under the CMS reporting schedule, but that later period does not extend the collection deadline.
What is the difference between SDoH and UDOH reporting?
UDOH is the terminology used in the updated CMS reporting materials for data commonly discussed as social determinants of health, or SDoH. The screening information concerns needs such as food, housing, and transportation.
Does demographic reporting still increase the Data Reporting adjustment?
Demographic reporting does not contribute to the PY2026 Data Reporting adjustment. The available adjustment of up to five percentage points is tied to UDOH reporting.
Can an unanswered survey count toward reporting?
An unanswered survey must be handled under the current CMS rules for documenting outreach and coding nonresponse. Preserve the attempt date and supporting records, then apply the implementation guide’s requirements rather than automatically classifying every unanswered survey as a decline.
Can practices use different screening tools?
Practices may use different CMS-approved screening tools. Each beneficiary’s submitted responses must come from a single instrument, so the central team should preserve the tool used for each record.
Does the end of ACO REACH end the ACO’s administrative responsibilities?
The end of the performance year does not complete every reporting, reconciliation, or closeout task. Maintain access to the staff, source records, and submission history needed to finish those responsibilities in 2027.
