CMS Proposes Rule To Improve Medicare Advantage Provider Directories
The proposed rule aims to increase accuracy of provider directories and reform pharmacy benefit manager payments. This change may benefit seniors by providing more reliable information about covered doctors and hospitals.
Original reporting · healthcaredive.com
Original: “CMS proposes rule to clean up MA provider directories, shine light on PBMs”
Read “CMS proposes rule to clean up MA provider directories, shine light on PBMs” at Healthcare Dive →
How this was written. Diagnosis Forward wrote this article with a language model from Healthcare Dive’s reporting (model: @cf/meta/llama-3.3-70b-instruct-fp8-fast); it describes that reporting rather than adding to it. The original, linked above, is the full story.
Key points from Healthcare Dive’s report
- The proposed rule aims to improve the accuracy of Medicare Advantage provider directories and reform pharmacy benefit manager payments.
- Medicare Advantage plans would be required to verify the accuracy of their provider directories at least every 90 days.
- Pharmacy benefit managers would be limited to flat service fees and required to provide annual reports to plan sponsors and the Centers for Medicare and Medicaid Services.
The Centers for Medicare and Medicaid Services has proposed a rule to implement key healthcare provisions, according to Healthcare Dive. This rule may improve the accuracy of Medicare Advantage plans' provider directories and reform how pharmacy benefit managers are paid.
The proposed rule would require Medicare Advantage plans to verify the accuracy of their provider directories at least every 90 days. Plans would also be required to update their directories if inaccuracies are found, which may help reduce errors.
Seniors who receive care from an out-of-network provider due to an inaccurate directory would not have to pay more than their in-network cost-sharing amount. This change may provide financial protection for seniors who are affected by directory errors.
The rule would also limit pharmacy benefit managers to flat service fees, which may increase transparency in their payment structures. These fees would not be based on factors such as drug prices or rebates, which could help reduce costs.
Pharmacy benefit managers would be required to provide annual reports to plan sponsors and the Centers for Medicare and Medicaid Services, which may help increase oversight of their activities. These reports would include details about their compensation and spending, as well as information about their formulary decisions.
The proposed rule is part of a larger effort to improve the accuracy of provider directories and increase transparency in the healthcare industry. The Centers for Medicare and Medicaid Services has been working to develop a national provider directory, which may eventually include data from Medicare Advantage organizations.
The rule may go into effect in 2028, with Medicare Advantage carriers required to publicly display accuracy scores in their provider lists by 2029. This change may help increase accountability and transparency in the industry.
Questions and answers
What is the purpose of the proposed rule?
The proposed rule aims to improve the accuracy of Medicare Advantage provider directories and reform pharmacy benefit manager payments, which may benefit seniors by providing more reliable information about covered doctors and hospitals.
How often would Medicare Advantage plans be required to verify the accuracy of their provider directories?
Medicare Advantage plans would be required to verify the accuracy of their provider directories at least every 90 days.
What information would pharmacy benefit managers be required to provide in their annual reports?
Pharmacy benefit managers would be required to provide details about their compensation and spending, as well as information about their formulary decisions, in their annual reports to plan sponsors and the Centers for Medicare and Medicaid Services.
