CMS Proposes 90-Day Provider Directory Checks for Medicare Advantage. Your Listing Is Part of It.
The Oct. 16 proposed rule would make plans verify every listed physician at least every 90 days, flag listings they cannot confirm and write directory upkeep into provider contracts. Comments are due Dec. 15.
On Oct. 16, the Centers for Medicare and Medicaid Services (CMS) announced a proposed rule that would require Medicare Advantage plans to verify and update their provider directories at least every 90 days and to report an accuracy score to the agency. If a patient sees an out-of-network physician because the directory listed that physician as in-network, the enrollee would pay no more than in-network cost sharing.
If your name, address, phone number or new-patient status appears in a Medicare Advantage directory, this rule is about you. The plans carry the legal duty, but the rule text makes clear the practical work will reach your front desk.
What the rule would require
The proposal, file code CMS-4214-P, implements three sections of the Consolidated Appropriations Act, 2026, signed Feb. 3. According to CMS's fact sheet, Section 6220, the Requiring Enhanced and Accurate Lists of (REAL) Health Providers Act, sets directory verification and maintenance standards, an annual accuracy analysis, public reporting of accuracy scores and cost-sharing protections for enrollees who rely on wrong listings. The requirements begin in contract year 2028. For contract year 2029, CMS would publish the scores in a machine-readable format and plans would have to display them prominently in their directories.
The rule text, filed for public inspection at the Federal Register on Oct. 16, adds detail that matters to practices. Plans would verify each listed provider at least every 90 days; acute inpatient hospitals, intensive care units and outpatient or ambulatory surgery facilities would be verified at least every 12 months. A listing the plan cannot verify would be marked in the directory as possibly out of date. A provider who has left the network would have to be removed within five business days, instead of the current 30-day standard. And plans would have to add a contract term obligating contracted providers to keep their directory information current and accurate.
The plan carries the legal duty. The practice will get the phone call, the email and, under the proposal, a contract clause.
How the checks would reach your office
Plans would have to use one or more CMS-specified methods: internal plan information, telephone or email contact, provider attestations, CMS data sources, claims data or other methods CMS names. CMS's own burden estimate assumes each direct contact takes about 15 minutes of a provider's time, or up to an hour a year for a provider verified every 90 days. CMS asks for comment on how often plans will actually contact providers and whether the work exceeds what practices already do.
The pharmacy benefit manager and Part D provisions
The same rule addresses Part D. Under Section 6224, pharmacy benefit managers would report their compensation and cost performance to plan sponsors and CMS each year, and their payments would have to reflect fair market value for services rather than drug costs. The fact sheet also describes disclosure of certain manufacturer agreements and enforcement that includes disgorgement of funds to CMS. Section 6219 would lower the Part D generic copayment from $1 to $0 for full-benefit dual-eligible individuals at or below 100 percent of the federal poverty level, for plan years starting Jan. 1, 2028. These provisions fall on plans and pharmacy benefit managers, not practices; our report on pharmacy benefit manager concentration covers the market they would regulate.
Timeline
The rule is scheduled for publication in the Federal Register on Oct. 20. The document sets the comment deadline at 5 p.m. Eastern on Dec. 15, 2026; comments should cite file code CMS-4214-P. CMS says a separate proposed rule on Parts C and D policy and technical changes will follow later this fall. Nothing is final, and the details, including how the accuracy score is calculated, could change.
What practices should do now
Check how you appear today. Pull your listings from the Medicare Plan Finder and from the directories of the Medicare Advantage plans that cover most of your patients, and compare locations, phone numbers, specialties and new-patient status. Name one person who owns directory updates, log each correction with a date and read the directory language in your next plan contract renewal.
Then decide whether to comment by Dec. 15. CMS has asked directly about the time providers spend on verification and how often plans will contact them, and practices and specialty societies are the ones who can answer that.
Reported, fact-checked and edited by The Script Pad's editorial staff.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
