CMS proposes MA directory checks and PBM pay rules
CMS wants Medicare Advantage plans to check their provider directories at least every 90 days.
A proposed rule released Oct 16 would also make plans report a directory accuracy score to CMS and show that score in the directory itself.
If a member sees an out-of-network doctor because the directory listed that doctor as in network, the member would pay no more than in-network cost sharing.
The same rule covers pharmacy benefit managers (PBMs) in Part D. PBMs would report their compensation to plan sponsors and CMS every year, and their pay would have to reflect fair market value for services instead of drug prices.
It also cuts the generic copay for the lowest-income dual eligibles from $1 to $0.
Most of it applies from 2028 and implements the spending law signed Feb 3, 2026. Comments are open for 60 days after the rule is published in the Federal Register.
Why it matters
When a listing is wrong, the plan pays the difference instead of the member, so plans get a direct cost reason to keep directories current.
Judi Health
PBS