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News
CMS is cracking down on inaccurate Medicare Advantage provider directories — the so-called "ghost networks" — and pushing for greater pharmacy benefit manager transparency. Under the proposed rule, MA plans must verify and update their provider directories every 90 days, with accuracy scores made public. The changes, stemming from the Consolidated Appropriations Act of 2026, are designed to shield beneficiaries from surprise costs and care disruptions.
CMS has proposed a sweeping set of reforms targeting two long-standing pain points in Medicare Advantage: inaccurate provider directories (a.k.a. "ghost networks") and opaque pharmacy benefit manager practices. The proposed rule, rooted in the Consolidated Appropriations Act of 2026, would require MA plans to verify and update their provider directories at least once every 90 days — and prominently display accuracy scores so beneficiaries can factor that information into plan selection.
On the financial protection front, if a plan's directory incorrectly lists a provider as in-network, enrollees would only be charged in-network cost-sharing rates. CMS also proposed restricting PBMs from tying their compensation to drug list prices, aiming to better reflect fair market value, alongside new transparency and reporting requirements for PBMs. Additionally, generic drug copayments for dual eligibles at or below the Federal Poverty Level would drop from $1 to $0 starting January 1.
By the Numbers:
Why it matters: Ghost networks have long left patients with unexpected bills after unknowingly seeing out-of-network providers. These reforms could meaningfully improve plan transparency and financial predictability for millions of Medicare Advantage enrollees.
