What Did CMS Propose on October 16?

On October 16, 2026, CMS proposed rule CMS-4214-P, which would require Medicare Advantage plans to verify and update provider directory information at least every 90 days, report an accuracy score to CMS and display that score on their public directories. According to the CMS press release, members who rely on an inaccurate listing and end up seeing an out-of-network provider would pay no more than their in-network cost sharing. The changes are proposed for contract year 2028.

The rule implements three sections of the Consolidated Appropriations Act, 2026, which was signed into law on February 3, 2026. The CMS fact sheet lists them:

• Section 6220, the REAL Health Providers Act (Requiring Enhanced and Accurate Lists of Health Providers). It sets directory verification and maintenance standards, an annual accuracy analysis, public accuracy scores and cost-sharing protections, starting in contract year 2028.
• Section 6224, PBM accountability. It sets rules for how pharmacy benefit managers are paid in Part D, along with reporting, price guarantee transparency and enforcement.
• Section 6219, Part D cost sharing for low-income members. It lowers the generic drug copay from $1 to $0 for full-benefit dual eligible individuals at or below 100% of the Federal Poverty Level, for plan years starting January 1, 2028.

“The actions we are proposing today will give Medicare Advantage and Part D enrollees more reliable information, stronger financial protections, and greater confidence in both programs,” CMS Administrator Mehmet Oz said in the announcement. Comments are open for 60 days after the rule is published in the Federal Register. CMS has not yet set a publication date, so the comment deadline is not final. CMS also said it expects to release a separate Parts C and D policy rule later this fall.

The Rules That Apply During This AEP

Several directory rules already apply to the 2027 plans your clients are choosing. Under the second final rule on provider directories for Medicare Plan Finder (CMS-4208-F2), codified at 42 CFR 422.111(m), Medicare Advantage organizations must submit their directory data to CMS for use in Plan Finder, update it within 30 days of learning about a change, and attest at least once a year that it is accurate. All of this is explained in the CMS technical implementation guide.

For 2027, CMS moved from a vendor-supplied interim data set to directory files that each plan submits itself. CMS says in its provider directory office hours Q&A that the 2027 directory data was scheduled to go live in Plan Finder on October 1, 2026, and that CMS downloads, ingests and validates plan data every day at around 4:00 a.m. ET. CMS’s plan preview memo adds that Plan Finder shows a practitioner’s or facility’s 15 closest locations to the ZIP code entered and flags which of them are in network.

For consumers, the Medicare & You 2027 handbook tells people they can add their most important providers at Medicare.gov/plan-compare to see whether those providers are in network, and that they can also contact the provider directly. That second sentence is the most important one for brokers.

The stakes are real. KFF has found that Medicare Advantage enrollees can access, on average, about half of the physicians available to traditional Medicare beneficiaries in their area. Narrow networks are not automatically bad. But they make an accurate directory, and an accurate broker conversation, essential.

Today vs. 2028 vs. 2029

The REAL Health Providers Act text in Congress (S.3750 and H.R.5281) gives more detail than the CMS summary. Here is how the requirements stack up over time. The final CMS rule may differ from the proposal.

The bill text also lists the fields a directory must keep accurate: name, specialty, contact information, office or facility addresses, whether the provider is accepting new patients, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities. Plans would also have to tell members about the cost-sharing protection, to the extent practicable, by the first day of each Annual Enrollment Period.

A Five-Step Network Check for Every Appointment

The best protection for your clients, and for your book, is a repeatable network check that you document every time. Here is a workflow you can use this AEP:

1. Collect the provider list. Primary care doctor, every specialist, preferred hospital, any upcoming surgery or treatment, and any facility the client uses, such as dialysis, imaging or physical therapy. Capture the full name and office address, since networks can vary by location.
2. Run each provider in Plan Finder. Add providers at Medicare.gov/plan-compare and compare the in-network flags across the plans the client is considering.
3. Cross-check the carrier directory. Search the carrier’s 2027 directory for the exact plan and, if one applies, the plan segment, not only the carrier brand. HMO, PPO and D-SNP networks under the same carrier can differ.
4. Have the client call the office, or call together. Ask: “Are you in network with [plan name] for 2027, at this location, and are you accepting new patients?” Write down the date, the office contact and the answer.
5. Document and set a January check. Note the verification in the client file, then confirm the first appointment in January. Problems found early are much easier to fix.

A practical example

A client on a PPO plan that is ending wants to stay with her cardiologist. Plan Finder shows him in network for two HMO options. The carrier directory lists him at one of his three offices, and his office confirms it accepts one of the two HMOs at that location only. That one phone call turns a likely billing problem in March into a clean enrollment, and a documented reason for the plan you recommended.

When a Doctor Leaves Mid-Year

Providers can leave Medicare Advantage networks at any time during the year. Under current rules, a Special Enrollment Period for a significant change in the provider network applies only when CMS determines that a change is “significant,” for example a plan losing a large hospital system. As KFF documented, CMS proposed in 2026 to drop that determination and make the SEP available to any affected enrollee, but declined to finalize the change and noted that it may come back in future rulemaking.

For brokers, that means a client whose doctor leaves mid-year usually cannot switch plans automatically. That is one more reason to choose a network carefully in the fall, and to watch the CMS rule expected later this fall for any revisions to the network SEP.

PBM Reforms and the $0 Generic Copay for Duals

The same proposal includes Part D changes brokers should know about, even though they take effect in 2028. PBMs would have to report their compensation and cost performance to plan sponsors and CMS every year, and PBM payments would have to reflect the fair market value of their services rather than drug prices, according to the CMS release. The fact sheet adds price guarantee transparency, disclosure of certain PBM agreements with manufacturers, and disgorgement of funds to CMS for violations.

For full-benefit dual eligible members at or below 100% of the Federal Poverty Level, the generic copay would drop from $1 to $0 starting with plan years that begin January 1, 2028. That is a meaningful talking point for brokers who serve dual eligible and D-SNP clients. Be clear that it is a future change and does not affect 2027 copays.

Compliance Guardrails

• Scope of Appointment first. A written Scope of Appointment is still required before a personal marketing appointment, though the 48-hour wait ended on October 1, 2026. See our Scope of Appointment rules update.
• Never guarantee a provider. Say “the office confirmed today that they participate for 2027 at this location,” not “your doctor will always be covered.”
• Describe the rule as proposed. The 90-day verification, accuracy scores and cost-sharing protection are not yet in effect. Do not tell clients they are protected from directory errors in 2027.
• Use the required TPMO disclaimer and follow call recording requirements before discussing plan benefits.
• Present Original Medicare fairly. For clients who need broad provider access, review the Medigap path as well. Our Medicare Advantage vs. Medicare Supplement guide covers the trade-offs.

Common Broker Mistakes

• Checking the carrier, not the plan. A doctor who takes one carrier’s PPO may not be in its HMO or D-SNP network.
• Relying on one source. Plan Finder, the carrier directory and the provider’s office can disagree. When they do, the office’s answer, documented, wins.
• Skipping facilities. Hospitals, dialysis centers and imaging centers matter as much as doctors.
• Ignoring the location. Many specialists practice at several sites with different network status.
• Quoting 2028 protections as current. They are a proposal.
• Not following up. A January call confirming the first appointment catches problems while fixes are still possible.

Why This Builds a Stronger Book

Clients rarely leave an agent over a premium. They leave after a surprise bill from a doctor they were told was covered. Brokers who make network verification a visible, documented part of every appointment build the trust behind long-term residual income. With benefits changing across many plans, as our Medicare Advantage benefit cuts for 2027 article explains, careful network work is one of the clearest ways to stand out this AEP. Agents who also sell under-65 coverage should prepare for November 1 with our ACA Marketplace OEP 2027 guide.

How Affordable Care Agents Supports Medicare Brokers

Affordable Care Agents is a national FMO, IMO and insurance brokerage. If you are new to the model, here is what an FMO does for brokers. During AEP, our brokers get:

• Carrier contracting across Medicare Advantage, Medicare Supplement, Part D, D-SNP and ancillary lines, so the right network is available for each client
• Compliance education on CMS marketing rules, Scope of Appointment, TPMO disclosures and documentation
• AHIP 2027 discount certification through our OIM partnership
• Back-office, enrollment and carrier-portal support during the busiest weeks of the year
• Training and coaching on needs-based appointments, including network verification workflows. Check your 2027 carrier certification dates and our AHIP 2027 certification guide if you are still finishing certifications

Frequently Asked Questions