Your Doctor Is In-Network. Probably. CMS Wants Medicare Advantage Plans to Prove It.

A letter grade on every directory, a cost-sharing penalty for every bad listing, and a 44% error rate CMS sat on for two years. What the CY2028 proposed rule means for plans, agents, and members.

1. Directories get a report card

Starting in contract year 2028, every MA plan has to verify every listed provider at least once every 90 days, with hospitals and facilities checked at least annually. Providers who can't be verified get flagged in the directory as potentially out of date, and departed providers must be removed within five business days.

2. The number CMS waited to publish

The preamble finally discloses the agency's own findings. CMS reviewed online directories from June 2022 to June 2024, covering 11,360 providers and 18,852 locations across 142 Medicare Advantage organizations. Of the location listings, 44.29 percent had at least one inaccuracy. The rate held across high-volume specialties: 45.73 percent of primary care listings, 47.66 percent of cardiology listings, and 45.67 percent of oncology listings had deficiencies.

3. A real penalty, with the burden of proof flipped

Here's the provision that changes member-service workflows. If an enrollee sees a provider who was listed as in-network in the online directory on the date the appointment was made, the enrollee owes the lesser of in-network or otherwise applicable cost sharing, even if the provider turns out to be out of network. That amount counts toward the out-of-pocket maximum.

4. Directories must disclose who owns the doctor

Among the nine directory elements required in each listing would be specialty, new-patient status, disability accommodations, cultural and linguistic capabilities, telehealth capabilities, and common ownership or control disclosure. In practice, directories will have to flag providers that sit inside the insurer's own corporate family. CMS frames this as useful to agents and brokers, which is a quiet acknowledgment of how much steering happens at the point of enrollment.

5. PBMs move to flat fees

On the Part D side, sponsors would have to limit PBM pay to flat-dollar, fair-market-value "bona fide service fees" that cannot be tied to drug price, rebates, or formulary placement, with fair market value defined as the cost of the itemized service plus a reasonable markup. Any payment that breaks the rule flows back from the PBM to the sponsor, and from the sponsor to CMS. CMS says it doesn't yet have sufficient data on PBM contract structures to estimate the financial impact, which tells you how opaque the current arrangements are.

6. $0 generics for the lowest-income duals

For plan years before 2028, generic copayments for full-benefit dual-eligibles at or below 100% of the federal poverty level are subject to a $1 statutory limit; from 2028 they drop to $0. CMS estimates about 6 million enrollees would be affected. Small per-fill, meaningful for adherence in exactly the population where it matters most.

What this means for agents

Every one of these provisions makes a good agent more valuable, because every one adds something a member needs to explain: what the grade means, why a provider is flagged, what ownership disclosure implies, and, most importantly, how to invoke the cost-sharing protection when a surprise out-of-network bill arrives. I expect the best agents to become practiced advocates in that process, pulling the booking date, requesting the archived directory snapshot, and holding the carrier to in-network cost sharing.

Timeline

Comments close December 15, 2026, 5:00 p.m. Eastern, under docket CMS-2026-2533. Verification, accuracy reporting, and cost-sharing protections take effect for contract year 2028; public grades follow in 2029. CMS says a separate Part C/D policy rule is expected later this fall. For plans, that means verification infrastructure and provider contract amendments need to be live by late 2027. For PBM contracts, every spread and percent-of-WAC fee has to be renegotiated before CY2028 bids are due in June 2027.