The Centers for Medicare & Medicaid Services proposed a rule implementing 2026 statutory reforms for Medicare Advantage and Part D. The regulation forces insurers to verify provider directories every 90 days starting in 2028, capping out-of-network costs for affected seniors. It also restricts pharmacy benefit managers to flat service fees, mandates rebate pass-throughs, and requires annual transparency reporting on retained revenue.
Medicare Advantage provider directory requirements
- ▪Starting in 2028, the proposed rule caps out-of-pocket costs at in-network rates for Medicare Advantage enrollees who receive care from out-of-network providers due to directory inaccuracies.
- ▪Under the proposed rule, Medicare Advantage plans must verify and update provider directory listings at least once every 90 days, with standards taking effect in 2028.
- ▪Medicare Advantage carriers will be required to report accuracy scores to the Centers for Medicare & Medicaid Services and publicly display them on directories by 2029.
Restrictions on pharmacy benefit manager fees
- ▪Under the proposed rule, pharmacy benefit managers in Medicare Part D cannot base fees on drug prices, generated rebates, or formulary placement, and must pass drug rebates through to plan sponsors.
- ▪The proposed Centers for Medicare & Medicaid Services rule restricts pharmacy benefit manager payments under Medicare Part D to flat service fees reflecting fair market value.
Pharmacy benefit manager transparency requirements
- ▪Under the proposed rule, pharmacy benefit managers must submit annual reports detailing compensation and cost performance to plan sponsors and the Centers for Medicare & Medicaid Services.
- ▪The proposed Centers for Medicare & Medicaid Services transparency provisions require pharmacy benefit managers to disclose spending and formulary decisions, including retained revenue, drug dispensing locations, and dispensed drugs.
Pharmacy contracting standards
- ▪The Centers for Medicare & Medicaid Services issued a Request for Information seeking stakeholder input on reimbursement rates and dispensing fees to establish Medicare Part D pharmacy contracting standards for 2027.
- ▪The Consolidated Appropriations Act gives the Centers for Medicare & Medicaid Services explicit authority to enforce a requirement that pharmacy benefit manager contract terms offered to pharmacies be reasonable and relevant.
Consolidated Appropriations Act of 2026
- ▪President Donald Trump signed the Consolidated Appropriations Act of 2026 in February 2026 to end a short government shutdown.
- ▪On October 16, 2026, the Centers for Medicare & Medicaid Services proposed a rule implementing healthcare provisions from the Consolidated Appropriations Act of 2026 signed into law in February 2026.
Medicare Advantage provider directory rules
- ▪Data collected from Medicare Advantage organizations under the proposed rule is intended to feed into a centralized national provider directory infrastructure across all U.S. insurers.
- ▪In fall 2025, the Centers for Medicare & Medicaid Services finalized a rule requiring Medicare Advantage plans to update provider directories within 30 days of changes.
Provider directory inaccuracy rates
- ▪A 2023 study found that upwards of 80% of provider listings contained inconsistencies across healthcare directories.
- ▪A 2018 Centers for Medicare & Medicaid Services review found Medicare Advantage provider directory inaccuracy rates ranged from 5% to 93% across examined health plans.
Cost-plus contracting models
- ▪Federal Trade Commission settlements with Express Scripts and CVS Caremark are accelerating a shift toward cost-plus contracting models for specialty pharmacy reimbursement.
- ▪Jesse Dresser cautioned that emerging cost-plus contracting models designed for retail pharmacies may lack adequate dispensing fees for specialty pharmacy work.
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