CMS proposes Medicare Advantage provider directory requirements for 2028

Medicare Advantage (MA) plans are set to face requirements aimed at improving the accuracy of provider directories, according to a proposed rule.

Issued Oct. 16 by CMS, the proposed regulations would implement provisions of the Consolidated Appropriations Act of 2026 (CAA 2026). Beginning in 2028, new mandates applicable to network-based MA plans and certain private fee-for-service arrangements would include regular verification and maintenance of provider directories, annual regulatory analyses and public reporting of directory accuracy, and cost-sharing protection for plan members who rely on incorrect directory information.

How cost-sharing protections would work

The cost-sharing protection ensures that if an enrollee sees a provider who was listed in-network in the online directory on the date the appointment was made, the enrollee owes the lesser of in-network or otherwise applicable cost sharing.

MA plans must contractually require providers to supply the earliest appointment date for documentation purposes, regardless of later rescheduling. That contractual provision must last at least 10 years past contract termination to ensure the obligation remains even if the provider no longer is in-network.

Plans also would be required to maintain daily archives of their online provider directories for at least 10 years and make records available to CMS within five business days of a request. The archives would help plans determine whether an enrollee relied on incorrect network information when scheduling an appointment.

The rule does not appear to address how the health plan and provider would settle payment when the cost-sharing protection applies. A 60-day comment period on the proposed rule runs through Dec. 15.

Provider directory verification and accuracy requirements

Among the nine directory elements to be included in each provider listing would be specialty, new-patient status, disability accommodations, cultural and linguistic capabilities, telehealth capabilities, and common ownership or control disclosure. Ownership disclosure would cover any network, provider, group, facility or supplier that is directly or indirectly owned or controlled by the MA entity, its parent, an affiliate or any entity under common control.

Mandatory verification cycles for directory information would take place every 90 days for most providers but only every 12 months for acute inpatient hospitals, critical care services and surgical services (outpatient or ambulatory surgery center).

“CMS selected these three types of entities because CMS believes that data for these specific entities is generally more static, as they may not move locations as often as other providers or facilities given their size and facility requirements,” the proposed rule states.

How CMS would assess provider directory accuracy

Starting in 2029, CMS would publish accuracy scores for provider directories, using a machine-readable format. MA plans would have to prominently display those scores in their directories.

Under the proposed sampling methodology, 35% of provider records selected for accuracy analysis would come from specialties designated as having high directory inaccuracy rates. The category initially would include mental health and substance-use disorder treatment providers. CMS also is considering primary care, cardiology and oncology for the designation.

The proposed requirements would follow a 2025 final rule obligating MA plans to include their provider directories on Medicare Plan Finder in time for 2027 open enrollment, which got underway Oct. 15 and runs through Dec. 7.

Research highlights longstanding directory inaccuracies

The issue of MA provider directories has gained greater attention in policy circles in recent years. As part of a 2021 appropriations law, Congress sought to address the problem in the context of commercial insurance, establishing that insurers by default are responsible for maintaining accurate provider directories. The 2021 legislation had similar protections (see page 7) to CAA 2026 with respect to cost-sharing for enrollees who based their choice of a provider on inaccurate directory information.

Among various indicators that policy and technological fixes continue to be needed, a 2023 study in JAMA found inconsistencies in physician address or specialty information among 81% of entries across the directories of five large national health insurers. The research highlights the challenges of maintaining consistent physician information across health plans.

Discrepancies were most likely to be found in addresses among physicians practicing at multiple locations, “which is concordant with prior research suggesting that most address errors stem from group practices reporting all physicians at all practice locations to insurers, irrespective of each individual physician’s practice locations,” researchers from the University of Colorado School of Medicine and a healthcare analytics company wrote in the study.

The authors placed the accuracy issue in the context of surprise billing. Under the No Surprises Act, “determining whether a physician is out of network hinges on accuracy of health insurer physician directories,” they wrote.

Rule also addresses Part D copayments and PBM transparency

As summarized in a fact sheet, the newly proposed rule also implements a CAA 2026 provision to reduce the Medicare Part D generic drug copayment from $1 to $0 beginning in 2028 for full-benefit dual-eligible beneficiaries whose income is at or below 100% of the federal poverty level.

Other aspects of the rule are designed to enhance accountability and transparency of pharmacy benefit managers (PBMs) in Medicare Part D, such as through restrictions on remuneration for PBMs and their affiliates, expanded reporting requirements to plan sponsors and CMS, and greater transparency around pricing guarantees.