CMS releases CAA Part D proposed rule

On Oct. 16, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule implementing provisions of the Consolidated Appropriations Act, 2026 (CAA) intended to improve the accuracy of Medicare Advantage (MA) provider directories and enhance PBM transparency and compensation requirements.

Among other provisions, the proposed rule would require MA plans to verify and update their provider directory information at least every 90 days and report an accuracy score to CMS. CMS also proposes that MA enrollees who receive out-of-network care due to inaccurate directory listings would pay no more than their in-network cost-sharing amount. Additionally, CMS proposes requiring PBMs to annually report their compensation and cost performance and would mandate that PBM payments reflect fair market value instead of drug costs.

CMS estimates the MA requirements would increase administrative and compliance costs, while noting the overall financial impact of the PBM provisions cannot currently be quantified because the agency lacks sufficient information about existing PBM contract structures and fee levels. However, CMS cites a Congressional Budget Office estimate that Section 6224 would reduce federal direct spending by approximately $444 million over 2026–2035.

Government Affairs is reviewing the proposed rule with impacted business areas with comments due Dec. 15. Most statutory requirements addressed by the proposal would apply beginning Jan. 1, 2028. CMS plans to release another proposed rule consisting of policy and technical changes for MA and Part D later this fall.