Proposed Rule: Medicare Advantage and Medicare Part D Updates
Article Publication Date
Summary
The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule that impacts the Medicare Advantage (MA) and Medicare Prescription Drug Benefit (Part D) programs.
The proposed rule amends the regulations for the MA program and the Part D program to implement key sections of the Consolidated Appropriations Act of 2026 (CAA), including:
• Reducing the generic drug copayment from $1 to $0 for full-benefit dual-eligible individuals at or below 100% of the Federal Poverty Level, starting Jan. 1, 2028 (Section 6219 of the CAA). CMS estimates this proposed change would affect approximately six million beneficiaries.
• Codifying regulations to implement the Requiring Enhanced and Accurate Lists of (REAL) Health Providers Act, which establishes new provider directory verification and accuracy requirements for MA organizations beginning in contract year 2028 (Section 6220 of the CAA). MA plans would be required to verify and update their provider directory information at least every 90 days and report an accuracy score to CMS. Plans would also prominently display these scores on their public-facing directories, empowering beneficiaries to choose plans with confidence. CMS also proposes codifying the statutory requirements for contract year 2029, including requiring CMS to publicly display provider directory accuracy scores in a machine-readable format and MA organizations to prominently display those scores in their provider directories.
• Proposals to add new requirements governing the remuneration that pharmacy benefit managers (PBMs) and their affiliates may receive for services in connection with the utilization of Part D drugs, data reporting by PBMs to Part D prescription drug plan (PDP) sponsors and CMS, and other requirements (Section 6224 of the CAA).
Comments are due on December 15 at 5:00 p.m.
The proposed rule amends the regulations for the MA program and the Part D program to implement key sections of the Consolidated Appropriations Act of 2026 (CAA), including:
• Reducing the generic drug copayment from $1 to $0 for full-benefit dual-eligible individuals at or below 100% of the Federal Poverty Level, starting Jan. 1, 2028 (Section 6219 of the CAA). CMS estimates this proposed change would affect approximately six million beneficiaries.
• Codifying regulations to implement the Requiring Enhanced and Accurate Lists of (REAL) Health Providers Act, which establishes new provider directory verification and accuracy requirements for MA organizations beginning in contract year 2028 (Section 6220 of the CAA). MA plans would be required to verify and update their provider directory information at least every 90 days and report an accuracy score to CMS. Plans would also prominently display these scores on their public-facing directories, empowering beneficiaries to choose plans with confidence. CMS also proposes codifying the statutory requirements for contract year 2029, including requiring CMS to publicly display provider directory accuracy scores in a machine-readable format and MA organizations to prominently display those scores in their provider directories.
• Proposals to add new requirements governing the remuneration that pharmacy benefit managers (PBMs) and their affiliates may receive for services in connection with the utilization of Part D drugs, data reporting by PBMs to Part D prescription drug plan (PDP) sponsors and CMS, and other requirements (Section 6224 of the CAA).
Comments are due on December 15 at 5:00 p.m.