CMS Proposes New Medicare Advantage Accountability Rules
The proposed rule introduces stricter transparency standards for pharmacy benefit managers and provider directories.
Updated on Oct. 16, 2026 in Healthcare
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The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule to implement key provisions of the Consolidated Appropriations Act of 2026. This move introduces new accountability requirements for pharmacy benefit managers (PBMs) and mandates improved accuracy in provider directories for Medicare Advantage plans.
Why it matters
The rule aims to enhance oversight of Medicare Advantage and Part D plans while reducing out-of-pocket costs for low-income beneficiaries. By standardizing directory data and PBM reporting, the government seeks to foster greater transparency and financial accountability in federal health programs.
The proposed rule mandates a reduction in generic drug copayments to $0 for qualifying dual-eligible individuals at or below 100% of the Federal Poverty Level. The regulation will be open for a 60-day public comment period following its official publication.
The players
Centers for Medicare and Medicaid Services
This federal agency within the U.S. Department of Health and Human Services administers the Medicare program and works with state governments to manage Medicaid.
The details
The REAL Health Providers Act within the proposal requires Medicare Advantage organizations to maintain and verify the accuracy of their provider directories. Additionally, Section 6224 mandates strict data reporting for PBMs, including potential disgorgement of funds to CMS if remuneration requirements are violated.
Timeline
February 3, 2026: The Consolidated Appropriations Act of 2026 was signed into law.
October 16, 2026: CMS issued the proposed rule.
January 1, 2028: Copayment reductions become effective for plan years.
Contract year 2028: Medicare Advantage provider directory verification requirements begin.
Contract year 2029: CMS will begin publicly displaying provider directory accuracy scores.
Market Landscape
This regulatory shift aligns with the Consolidated Appropriations Act of 2026 to increase federal oversight of private Medicare plans. It marks a departure from previous self-regulatory norms, forcing insurers and PBMs to align with standardized data reporting requirements.
For low-income Medicare beneficiaries, the proposed change promises a reduction in generic drug copayments to $0 starting in 2028. Other enrollees can expect more reliable provider directory information, as insurers will be required to maintain and report accurate data to CMS.
The takeaway
This rulemaking signifies a significant increase in the federal government's role in monitoring private Medicare plan operations and pharmacy pricing transparency. Beneficiaries should watch for future updates to their plan's provider directories as these new accuracy standards take effect.
Further reading
For more context on how federal reforms impact coverage, see the United States Healthcare section.
More information
To review the full text of the proposal, view this regulation on federal register.
Source note: This article includes information reported by Cms.
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