CMS proposes Medicare Advantage directory accuracy rules — what changes and when

On October 16, 2026, CMS proposed the rules that implement three Medicare provisions of the Consolidated Appropriations Act, 2026 — the spending law enacted on February 3, 2026. The package (CMS-4214-P) covers three things: how accurately Medicare Advantage plans must maintain their provider directories, a $0 generic-drug copay for one group of low-income Part D enrollees, and new conduct rules for pharmacy benefit managers (PBMs).

Two timing facts frame everything else. First, this is a proposed rule — CMS set a 60-day comment window that opens when the rule is published in the Federal Register, and at this writing it had been announced and posted for public inspection but not yet published. The details below can move before a final rule exists. Second, the statutes being implemented set their own start dates, and those dates are 2028 (with one piece in 2029). If you are picking a plan during the open enrollment window that runs through December 7, 2026, none of this changes your 2027 coverage.

The part most likely to matter to you: provider directories

When you compare Medicare Advantage plans, the provider directory is the tool you compare with: which doctors are listed as in-network, where, and taking new patients. Directory errors are common enough that Congress wrote a section of law about them, and an inaccurate listing is how a member ends up seeing an out-of-network doctor while believing the visit was covered.

The statute (section 6220, the REAL Health Providers Act) and the proposed rule would require each MA organization offering a specified MA plan — the statute’s term for plans that use a provider network, such as HMO- and PPO-type plans, plus certain private fee-for-service plans that build a network through contracts — to do the following, for plan year 2028 and later:

• maintain an accurate provider directory on a publicly available website, and verify and update it at least every 90 days (facilities such as hospitals may be updated less often, but no less than once every 12 months);
• run an annual accuracy analysis using a random sample of listed providers, including specialties with high inaccuracy rates, and report the results to CMS;
• publish an accuracy score, and — under a requirement already fixed in the statute for 2029 — present those scores in a machine-readable public format and display them prominently in the plans’ own directories.

The enforcement piece works through your bill. For plan year 2028 and later, if you are an enrollee in a specified MA plan and you receive a covered service from a provider who is listed in the plan’s directory on the day you made the appointment but is actually not in the network, the plan must limit what you owe to the lesser of two amounts: the cost sharing that would have applied if the provider had been in-network, or the cost sharing that would otherwise apply. Plans must also tell enrollees about the protection — by no later than the first day of the annual open enrollment window (October 15 through December 7), inside the directory itself, and in the first explanation of benefits of the plan year.

The $0 generic copay, and exactly who gets it

Section 6219 rewrites the low-income cost-sharing schedule in Part D. CMS’s fact sheet describes the affected group as full-benefit dual eligible individuals — people enrolled in both Medicare and Medicaid — whose income does not exceed 100 percent of the federal poverty level. For that group:

Drug type	Before 2028	Plan year 2028 and later
Generic drugs	up to $1	$0
Preferred multiple-source drugs	up to $1	prior-year amount, indexed to inflation
All other drugs	up to $3	prior-year amount, indexed to inflation

The statutory mechanics are worth stating plainly: from 2028 the generic copay is $0 outright, while the other two categories roll forward each year from the prior year’s amount, increased by the consumer price index (rounded to the nearest 5 or 10 cents). The “up to” in the first column matters too — those are statutory maximums, and a plan can charge less.

If you have Extra Help but are not a full-benefit dual eligible at or under 100 percent of poverty, this particular change does not reach you, though the broader Extra Help protections continue on their own terms.

The PBM piece, in one paragraph

Section 6224 imposes requirements on PBMs acting for Part D prescription drug plans, for plan years beginning on or after January 1, 2028: a PBM and its affiliates may not derive remuneration from Part D drug utilization other than bona fide service fees; rebates and discounts from manufacturers are not a violation if they are fully passed through to the plan sponsor and meet the program’s requirements for reporting manufacturer price concessions; PBMs must apply their pricing-guarantee definitions transparently and consistently and disclose certain agreement terms to the plans they serve; and a PBM that takes improper remuneration must disgorge it to the plan sponsor. This is the least visible of the three sections — it shapes the economics between PBMs, plans and manufacturers rather than creating a benefit you would notice at the pharmacy counter — and it is included here because it is the section most likely to be summarized in headlines as something it is not.

What is settled and what is not

The effective dates are settled, because they are in the law Congress enacted in February: the directory requirements and cost-sharing protection begin with plan year 2028, the score display requirements begin in 2029, the $0 generic copay begins with plan year 2028, and the PBM requirements begin with plan years starting on or after January 1, 2028.

Almost everything else is not settled. The October 16 rulemaking is a proposal: CMS is proposing definitions, compliance mechanics and enforcement processes, and the comment period — 60 days from Federal Register publication — can change them. A final rule has not been issued, and the boundaries of terms like “accurate” and how the accuracy score is calculated are exactly the kind of detail that moves between proposal and final.

What to do during this open enrollment

1. Verify a provider the way the future rule assumes you should. When a plan’s directory lists a doctor you want, call the doctor’s office and confirm they accept that plan for 2027. Do that before you switch. The plan-shopping steps are in Medicare open enrollment 2027.
2. Do not count 2028 protections in a 2027 decision. The lesser-of cost-sharing rule does not exist yet. If a plan’s directory is wrong this year, today’s rules — not the proposed ones — apply.
3. If you are a dual eligible watching drug costs, the 2028 generic copay change is on the calendar, but the 2027 numbers are what your plan will charge next year. The other January 1 changes are covered in Medicare’s second round of negotiated drug prices.
4. Hang up on anyone who charges a fee for any of this. There is no application, no enrollment and no fee connected to the directory protections or the $0 copay — the statute and the rule operate on plans and PBMs, not on you. Open enrollment is peak season for callers who invent fees for changes that happen automatically, and the warning signs are collected in Medicare open enrollment 2027.

Bottom line

CMS proposed the implementing rules for three Medicare provisions of the 2026 spending law: accurate, 90-day-verified provider directories with an annual public accuracy score, a cost-sharing cap for enrollees who rely on a wrong directory entry, a $0 generic copay for full-benefit dual eligibles at or under 100 percent of the poverty level, and a set of conduct rules for PBMs. The statute fixes the start dates in 2028 (scores displayed in 2029); the rule itself is a proposal with a 60-day comment window that opens at Federal Register publication. For the plan you pick this December, nothing in it applies — the directories, copays and networks in front of you right now still run on 2027 rules. Medicare is a federal program, but which plans are sold where — and whose networks they list — varies by state and county, so the directory check in this article is only as good as the listings for your own ZIP code.

For plan comparisons, see Medicare open enrollment 2027; for how MA plan availability is changing next year, see Your Medicare Advantage plan may not be there in 2027; a survey of the network’s guides is at omc.center/resources.