CMS issues provider directory and PBM transparency rule

On October 16, 2026, the Centers for Medicare & Medicaid Services proposed a rule implementing healthcare reforms from the Consolidated Appropriations Act of 2026, signed by President Donald Trump in February 2026. The rule mandates that Medicare Advantage plans verify provider directories every 90 days and cap out-of-network costs for inaccurate listings. It also restricts pharmacy benefit managers to flat service fees, requires full rebate passthroughs, mandates annual PBM spending reports, and eliminates generic co-pays for dually eligible low-income seniors.

Proposed requirements for provider directories

• ▪Under the Centers for Medicare & Medicaid Services proposed rule issued on October 16, 2026, seniors receiving out-of-network care due to inaccurate directories will not pay more than in-network cost sharing.
• ▪The Centers for Medicare & Medicaid Services proposed rule issued on October 16, 2026 requires Medicare Advantage carriers to report accuracy scores to the agency and publicly display them on directories by 2029.
• ▪On October 16, 2026, the Centers for Medicare & Medicaid Services proposed a rule requiring Medicare Advantage plans to check and update their provider directories at least once every 90 days.

Restrictions on pharmacy benefit manager fees

• ▪The Centers for Medicare & Medicaid Services proposed rule issued on October 16, 2026 limits pharmacy benefit managers to flat service fees reflecting fair market value for Medicare Part D services.
• ▪Under the October 16, 2026 proposed rule, pharmacy benefit manager fees cannot be based on drug prices, rebates generated, or formulary placement, and all drug rebates must be passed to Part D plan sponsors.

Reporting requirements for pharmacy benefit managers

• ▪Under the proposed rule, pharmacy benefit managers' annual reports must detail dispensed drugs, dispensing locations, formulary decisions, and revenue retained from transactions.
• ▪The October 16, 2026 proposed rule requires pharmacy benefit managers to submit annual reports on compensation, spending, and cost performance to plan sponsors and the Centers for Medicare & Medicaid Services.

Studies on provider directory inaccuracies

• ▪A 2018 Centers for Medicare & Medicaid Services review of Medicare Advantage directories found listing inaccuracies ranging from 5% to 93% depending on the plan examined.
• ▪A 2023 study found that upwards of 80% of provider listings contained inconsistencies.