The Regulator

90 days: that is how often Medicare Advantage plans would have to verify their provider directories, under a proposed rule the Centers for Medicare & Medicaid Services (CMS) issued October 16. Plans would also report a directory accuracy score to CMS, and those scores would be shown publicly. A patient who books a provider listed as in network, and turns out to be out of network, would pay no more than in-network cost-sharing. The same proposal (CMS-4214-P) takes on pharmacy benefit managers (PBMs), the middlemen that negotiate drug prices for Part D plans: they would report their compensation and cost performance to plan sponsors and CMS each year, and their pay would have to reflect the fair market value of services rather than the price of the drugs. Trade press reports the fees would become flat-dollar and itemized starting January 1, 2028; that detail is not in the CMS release, so check the rule text. A third provision cuts the generic-drug copay from $1 to $0 for full-benefit dual-eligible people at or below 100% of the federal poverty level, beginning in plan year 2028. Directory rules start in contract year 2028, with public scores in 2029. Comments are open 60 days after Federal Register publication; trade press reports a December 15 deadline, which we could not confirm. CMS gives no dollar estimate, and says a second Parts C and D proposal is coming later this fall. Who it hits: Medicare Advantage insurers, PBMs and their affiliates, and the Part D plans that contract with them. Confidence: High on the provisions in the CMS release and fact sheet; Med on the flat-fee detail and deadline. Sources: CMS press release, CMS fact sheet, CMS-4214-P, supplemental: Fierce Healthcare.

CMS announced $92 million in Rural Health Transformation money for Ohio on October 16, plus more than $11 million for New Hampshire and $3.63 million for Montana. Ohio’s split: $31.4 million for coordinated care networks, $30.3 million for maternal care at rural hospital networks and health centers, and $30.3 million in one-time upgrades at 22 rural hospitals, including a new behavioral health unit and on-site MRI. New Hampshire’s money goes to rural towns, emergency medical services (EMS) agencies and health systems for mobile integrated health programs, and Gov. Kelly Ayotte called it the largest rural health transformation award in New England. Montana’s goes to 17 rural EMS agencies for staffing, transport, equipment and training to provide in-home care. None of the three releases states the state’s full fiscal 2026 award, so the share these amounts represent is not known. The program is a $50 billion national fund. Confidence: High on the announced figures. This continues our October 16 coverage of Texas. Sources: CMS press release, Ohio, CMS press release, New Hampshire, CMS press release, Montana.

CMS and the Small Business Administration promoted “CHOICE Arrangements” at an Ohio employer event on October 16. CMS says CHOICE Arrangements is the new name for individual coverage health reimbursement arrangements (ICHRAs), which let an employer give workers a tax-advantaged sum toward individual health coverage, or Medicare, instead of a group plan. CMS Administrator Mehmet Oz spoke alongside SBA Deputy Administrator Bill Briggs and the CEO of Take Command, a vendor of these arrangements. The release gives no enrollment figure, dollar amount or new rule, so treat it as promotion of an existing option for small businesses facing rising group premiums. Confidence: High on the event; Low on any practical effect. Sources: CMS press release, CHOICE in Action.