CMS Proposes to Implement PBM and Provider Directory Changes in Medicare Advantage

The Centers for Medicare & Medicaid Services (CMS) on Oct. 16 released a proposed rule implementing provisions of the Consolidated Appropriations Act (CAA), 2026 (P.L. 199-75). The proposed rule seeks to implement provisions of the CAA related to Medicare Advantage (MA) and Medicare Part D plans but is separate and distinct from the CY 2028 Medicare Advantage and Part D Policy and Technical Changes proposed rule, which is slated for release later this fall. 

To implement these provisions, the proposed rule would establish new provider directory and accuracy requirements for MA organizations, modify standards for contracts between Part D sponsors and pharmacy benefit managers (PBMs), and limit Part D cost sharing for Medicare-Medicaid dual-eligible beneficiaries whose incomes do not exceed 100% of the federal poverty limit. Under the CAA, beginning in plan year 2028, MA plans are required to maintain an accurate provider directory on their website and verify that the information is accurate at least once every 90 days. To implement these requirements, the CMS proposed a scoring methodology to weigh the accuracy of a provider directory using a letter grade, which would be made public in 2029. The agency further proposed to limit MA beneficiaries’ cost sharing for out-of-network services to no more than the in-network amount in cases where a beneficiary unknowingly receives care from an out-of-network provider due to an inaccurate provider directory. While the onus of these changes is on MA plans, providers will be asked to confirm information to update provider directories on a more frequent basis. The rule also includes new transparency and reporting requirements for pharmacy benefit managers, as required by the CAA. 

Comments on this proposed rule are due Dec. 15.