The Centers for Medicare and Medicaid Services has taken the first steps to implement “ghost network” and pharmacy benefit manager reforms outlined by Congress in its February appropriations package.
The proposed rule (PDF) issued Friday outlines a framework for Medicare Advantage plans to verify and update their provider directories at least once every 90 days, according to a release and fact sheet from the agency.
Accuracy scores from these checks will be “prominently displayed” in plan directories, while CMS will publish the results in a machine-readable format, allowing beneficiaries to consider directory accuracy when choosing a plan. CMS also proposed requiring Medicare Advantage plans to limit enrollees’ cost sharing to in-network rates when a plan’s directory incorrectly lists a provider as in-network.
As proposed, the provider directory reviews and cost-sharing protections will take effect in the 2028 contract year, while publication of accuracy scores is slated for contract year 2029, according to the proposed rule. CMS said these changes will head off unexpected costs and care disruptions for patients.
“CMS has been working to improve data connectivity and accuracy in provider directories across the healthcare system,” Administrator Mehmet Oz, M.D., said in a release. “The actions we are proposing today will give Medicare Advantage and Part D enrollees more reliable information, stronger financial protections and greater confidence in both programs.”
Landing alongside the provider directory changes is a proposal to restrict pharmacy benefit managers from tying compensation in Part D to the list price of drugs, which CMS said would “reflect fair market value for services provided, rather than drug costs.” Additionally, the proposed rule outlines various transparency, reporting and disclosure requirements for PBMs, CMS said.
Finally, CMS moved to codify a reduction in generic drug copayments for dual eligibles at or below the Federal Poverty Level, from a $1 maximum to $0, beginning Jan. 1. The removal of even small barriers such as this is expected to improve medication compliance, officials have said.
CMS, in the proposed rule, said it expects the provider directory requirements will increase administrative and compliance costs for MA organizations. The agency also said that it doesn’t (yet) have sufficient data on PBM contract structures and fee structures to estimate the financial impacts of the proposed PBM changes, and that the Medicare program will be absorbing the generic copayment change.
Friday’s proposed rule reflects the statutory requirements of the Consolidated Appropriations Act of 2026, signed into law in February by President Donald Trump after it moved through Congress with the support of some Senate Democrats. The package also included several key extenders to telehealth and hospital-at-home allowances, as well as often-renewed supplementary funding programs for rural hospitals and those with high proportions of government-insured patients.