The Centers for Medicare & Medicaid Services issued a proposed rule requiring Medicare Advantage plans to improve the accuracy of their provider directories and establish new transparency standards for pharmacy benefit managers.
Under the proposal, Medicare Advantage plans would be required to verify and update their provider directory information at least every 90 days and report an accuracy score to CMS. The scores would be displayed on plans' public-facing directories so beneficiaries can identify which plans have more reliable information.
CMS Administrator Dr. Mehmet Oz said the measures will strengthen protections for enrollees. "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," he said.
The proposal also protects beneficiaries from unexpected costs and care disruptions when inaccurate directories lead them to use out-of-network providers. Under the rule, such enrollees would pay only the in-network cost-sharing amount they would have owed.
Additionally, the proposal requires Pharmacy Benefit Managers (PBMs) to report their compensation and cost performance to plan sponsors and CMS annually. PBM payments would need to reflect fair market value for services provided, rather than drug costs.
The proposed changes are for Medicare contract year 2028. The proposed rule will be open for public comment for 60 days following publication in the Federal Register. CMS plans to release additional Medicare policy and technical changes later this fall.