A Medicare Advantage plan must honor its directory from contract year 2028. A visit booked while the provider was listed as in-network carries in-network cost sharing even after the provider leaves the network (CMS proposed rule CMS-4214-P, October 2026). For an HMO that turns a denied claim into a paid one. CMS prices the change at 1.5 staff hours a request.
CMS released the rule on October 16, 2026, with a press release and a fact sheet. Federal Register publication is scheduled for October 20, and comments are due December 15 (CMS press release, October 2026). Section 6220, the REAL Health Providers Act, adds 90-day directory verification, a public accuracy score and the cost-sharing protection. Administrator Mehmet Oz said the package "will give Medicare Advantage and Part D enrollees more reliable information" (CMS press release, October 2026). The impact analysis budgets staff hours for the protection and no claim dollars.
Key Takeaways
- CMS's three directory review rounds found more than two in five listings deficient: 8,350 of 18,852 locations, 44.29% across 2022 to 2024.
- The impact analysis assumes one protection request per contract a year: 708 requests, costed at 1.5 staff hours each, $95,962 in total.
- Plans must build a daily directory archive kept ten years: $4,032,768 one-time plus $1,008,192 a year, most of the REAL Act burden.
- Network status drives both exposures: it carries 40% of the accuracy score published from 2029 and is the only error that triggers the protection.
The Three Provisions and When Each Starts
Section 6220 of the Consolidated Appropriations Act, 2026 (Pub. L. 119-75), enacted February 3, amends section 1852(d) of the Social Security Act. It reaches "specified MA plans": network-based plans, plus private fee-for-service plans that meet access standards through a provider network (CMS proposed rule CMS-4214-P, October 2026). Its requirements begin in contract year 2028. The rule builds on 42 CFR 422.111(m), in force for 2026 plan years, which already requires Plan Finder submissions, 30-day updates and an annual accuracy attestation (90 FR 45140, September 2025).
Verification tightens first. Plans check every directory entry at least once every 90 days, with a 12-month cycle for hospitals and other facilities the Secretary designates. The accuracy score follows, under proposed 422.123(d)(4). Each year the MA organization samples its own directory using CMS's sampling method, computes the weighted composite under CMS's scoring method, and reports the score to CMS. Grades run from A at 90% and above to F at 49% and below. Beginning in contract year 2029, CMS publishes the scores in machine-readable form and plans display them in their directories (CMS proposed rule CMS-4214-P, October 2026).
| Scored directory element | Weight |
|---|---|
| Network participation status | 40% |
| Contact information, including phone | 20% |
| Primary office or facility address | 20% |
| Specialty | 10% |
| Accommodations for people with disabilities | 3.5% |
| Telehealth capabilities | 3.5% |
| Accepting new patients | 3% |
CMS's worked example, "MA plan Y", got five of six network statuses right, three of six phone numbers and four of six addresses. It scored 73%, a C (CMS proposed rule CMS-4214-P, Table II.B.5). Section 6224 rewrites PBM pay in Part D from 2028: bona fide service fees only, flat dollar amounts at fair market value with no link to rebates, list price or formulary placement. The site's coverage of the CAA rebate pass-through mandate and the 2029 passthrough timetable carries that detail.
The Cost-Sharing Protection as a Benefit Change
New section 422.124 applies when a provider was listed as in-network on the appointment date but is out-of-network when the service is furnished, and the service would be covered in-network. The enrollee then pays the lesser of in-network cost sharing or the cost sharing that would otherwise apply (CMS proposed rule CMS-4214-P, October 2026). Plans apply it without a request whenever they know or reasonably should know it applies. The protected amount counts as in-network spending toward the MOOP limit under 422.124(g)(2).
For an HMO the arithmetic is a full claim. An out-of-network visit is ordinarily uncovered, so the protected service becomes a paid claim at in-network cost sharing that the plan would otherwise have denied. For a PPO the plan absorbs the gap between out-of-network and in-network cost sharing on a claim it was already paying. Either way the protected dollars count toward the in-network MOOP and bring forward the point where the plan pays 100%.
Section 422.124(f) turns documentation into claims cost. If a plan cannot document the appointment date, or cannot verify its archived directory data within the organization-determination timeframes, the protection applies in the enrollee's favor by default. Hence the daily directory archive, kept at least 10 years and produced to CMS within 5 business days. CMS prices it at 28,320 hours and $4,032,768 to build, plus $1,008,192 a year to maintain (CMS proposed rule CMS-4214-P, Tables III.7A and III.7B).
Set beside that archive, the request budget is small. CMS assumes 708 requests a year, one per MA organization contract, at 1.5 hours each: $95,962. Refunds run 708 at 0.5 hours, $31,987 (CMS proposed rule CMS-4214-P, October 2026). The whole REAL Act burden comes to $6,025,071 in the first year and $1,608,453 a year after that.
In the ten-year table the Act appears only as cost, $20.5 million across 2028 to 2037 (CMS proposed rule CMS-4214-P, Table IV.1). The one quantified transfer is Section 6219, which cuts the generic copay to $0 for full-benefit dual eligibles at or below 100% of poverty: $99.0 million in 2028 and $1,337.0 million over ten years. No line estimates the cost-sharing dollars the protection moves from enrollees to plans.
CMS's own reviews point the other way. Three online directory review rounds from June 2022 to June 2024 covered 11,360 providers at 18,852 locations. Of those, 8,350 locations were deficient, 44.29% (CMS proposed rule CMS-4214-P, Tables II.B.1 and II.B.2). The tables do not split deficiencies by element. A wrong phone number costs nothing under 422.124; only a wrong network status triggers the protection, and the reviews do not isolate that share. CMS itself calls request volume highly uncertain, depending on inaccuracy prevalence and enrollee awareness.
Pricing the load for a 2028 bid therefore needs three inputs the rule leaves out. One is the count of visits booked against a listing that later went out-of-network. Another is the relief per visit: a full claim for an HMO, a cost-sharing gap for a PPO. A third is uptake, which turns on enrollee awareness and on how many cases the plan catches under the knows-or-should-know standard. Contract year 2028 bids are due the first Monday in June 2027, before a single 90-day verification cycle under the new rule has run.
The Pruning Incentive Against Network Adequacy
Network participation status carries 40% of a score that becomes public in contract year 2029, and the protection pays out on exactly that element. A plan therefore has two reasons to cut any listing it cannot confirm within a 90-day cycle. An unlisted provider cannot be drawn into the accuracy sample or trigger 422.124. Adequacy review reads the contracted-provider lists a plan files in its Health Service Delivery tables, so pruning leaves the tested network untouched. Each deletion opens a gap between the network the plan files for adequacy and the one enrollees see in Medicare Plan Finder.
PCPs, cardiologists and oncologists all ran at 45% or above, and CMS considered designating the three as high-inaccuracy specialty types. It did not propose the designation and asks for comment (CMS proposed rule CMS-4214-P, October 2026). The site's coverage of 21 health systems dropping MA plans showed filed networks shrinking from the provider side. A directory purge runs the other way: the filed network stays whole for the adequacy review while the displayed one shrinks.
The same June 2027 bid absorbs Section 6224. Table I.1 says the PBM fee change cannot be estimated, given no data on PBM contract structures or on how far current fees sit from fair market value (CMS proposed rule CMS-4214-P, October 2026). The one outside estimate the rule cites says delinking could cut net drug spending by about 15%. A bid actuary signing in June 2027 prices a directory claims load CMS calls uncertain next to a pharmacy fee reset CMS says it cannot size. Both land in one bid, and the daily archive that would measure the first starts recording in contract year 2028.
Further Reading
- Federal PBM Rebate Mandate Rewrites Employer Pharmacy Trend Models: the CAA 2026 pharmacy provisions this rule implements on the Part D side.
- Federal PBM Reform Mandates Full Rebate Passthrough by 2029: the passthrough timetable that sits behind the Section 6224 fee rules.
- 21 Health Systems Drop MA Plans, Exposing Network Adequacy Gaps Actuaries Must Price: the provider-side version of the network shrinkage this rule can trigger from the plan side.
- CMS's 2027 Rebate Reallocation Rule Drives MA-PD Part D Premiums to Zero: the other CMS rule reshaping the 2027 bid cycle.
- CMS 2027 Star Ratings: 188 Contracts at Four Stars: the existing public scorecard the 2029 directory accuracy score will sit beside.
Sources
- CMS proposed rule CMS-4214-P, Medicare Program: Implementation of Sections 6219, 6220, and 6224 of the Consolidated Appropriations Act, 2026 (Federal Register public inspection, FR Doc. 2026-21420)
- CMS press release, October 16, 2026: CMS proposes reforms to strengthen transparency and affordability in Medicare Advantage and Part D
- CMS fact sheet, October 16, 2026: Implementation of Sections 6219, 6220, and 6224 of the Consolidated Appropriations Act, 2026