Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE)-Finalization of Format Provider Directories for Medicare Plan Finder

<RULE> DEPARTMENT OF HEALTH AND HUMAN SERVICES <SUBAGY>Centers for Medicare & Medicaid Services</SUBAGY> <CFR>42 CFR Part 422</CFR> <DEPDOC>[CMS-4208-F2]</DEPDOC> <RIN>RIN 0938-AV40</RIN> <SUBJECT>Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE)—Finalization of Format Provider Directories for Medicare Plan Finder</SUBJECT> <HD SOURCE="HED">AGENCY:</HD> Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS). <HD SOURCE="HED">ACTION:</HD> Final rule. <SUM> <HD SOURCE="HED">SUMMARY:</HD> This final rule implements Medicare Advantage disclosure requirement changes. </SUM> <EFFDATE> <HD SOURCE="HED">DATES:</HD> <E T="03">Effective date:</E> These regulations are effective November 17, 2025. <E T="03">Applicability date:</E> This final rule is applicable beginning January 1, 2026. </EFFDATE> <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Naseem Tarmohamed, (410) 786-0814. </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> <HD SOURCE="HD1">I. Executive Summary</HD> <HD SOURCE="HD2">A. Purpose</HD> The primary purpose of this final rule is to amend the regulations pertaining to disclosure requirements under 42 CFR 422.111 for the Medicare Advantage (MA) (that is, Part C) program. In this final rule, CMS is finalizing a new requirement that will increase beneficiaries' access to provider data while comparing plans in the CMS Medicare Plan Finder (MPF) tool, which will contribute to the beneficiaries' ability to make more informed decisions about their health care. <HD SOURCE="HD2">B. Summary of the Provision—Format Provider Directories for Medicare Plan Finder</HD> CMS is finalizing the proposed requirement for MA provider directory data to be submitted to CMS/HHS for publication online in accordance with guidance from CMS/HHS. In addition, CMS is finalizing the proposal that MA provider directory data be updated within 30 days of the date an MA organization becomes aware of changes to that data. CMS is also finalizing the proposal to require MA organizations to attest at least annually that the MA provider directory information is accurate when the attestation is provided to CMS. These regulatory changes will further promote informed beneficiary choice and transparency found in online resources, empowering people with Medicare to make informed choices about their coverage. CMS is not finalizing the portion of the proposal that would have required MA organizations to attest that their MA provider directory data are consistent with data submitted to comply with CMS's MA network adequacy requirements under § 422.116(a)(2)(i). MA organizations already attest that they have an adequate network for access and availability of a specific provider or facility type. <HD SOURCE="HD2">C. Summary of Costs and Benefits</HD> <GPOTABLE COLS="3" OPTS="L2,nj,i1" CDEF="s50,r150,r50"> <TTITLE>Table 1—Summary of Costs and Benefits</TTITLE> <CHED H="1">Provision</CHED> <CHED H="1">Description</CHED> <CHED H="1">Financial impact</CHED> <ROW> <ENT I="01">Format Provider Directories for Medicare Plan Finder</ENT> <ENT>To require MA provider directory data, as required under § 422.111(b)(3)(i), to be submitted to CMS/HHS for publication online in a format, manner, and timeframe determined by CMS/HHS. Additionally, to also require MA organizations to attest at least annually that this information is accurate when the attestation is submitted to CMS in accordance with guidance from CMS/HHS. CMS is not finalizing the portion of the proposed attestation requirement that would have required MA organizations to attest that the provider directory data are consistent with data submitted to comply with CMS's MA network adequacy requirements at § 422.116(a)(2)(i). MA organizations already attest that they have an adequate network for access and availability of a specific provider or facility type</ENT> <ENT>These changes will not affect the Medicare Trust fund. The paperwork burden is $500,000 annually.</ENT> </ROW> </GPOTABLE> <HD SOURCE="HD2">D. Publication of the Proposed and Final Rules</HD> The proposed rule titled “Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly” appeared in the December 10, 2024, <E T="04">Federal Register</E> (89 FR 99340) (hereinafter referred to as the “December 2024 proposed rule”). In response to the December 2024 proposed rule, CMS received approximately 31,227 timely pieces of correspondence containing multiple comments on the proposed rule, with approximately 130 received about the provision to format provider directories for MPF being finalized here. CMS notes that some of the public comments were outside of the scope of the proposed rule. In the subsequent final rule of the same title that appeared in the April 15, 2025, <E T="04">Federal Register</E> (90 FR 15792) (hereinafter referred to as the “April 2025 final rule”), CMS finalized several of the provisions from the proposed rule and noted the provisions of the proposed rule that would not be addressed or finalized. CMS also indicated that any remaining provisions may be finalized in subsequent rulemaking, as appropriate. For more information, see the April 2025 final rule (90 FR 15891). <HD SOURCE="HD1">II. Proposal To Format MA Organizations' Provider Directories for Medicare Plan Finder (§§ 422.111 and 422.2265) and Analysis of and Responses to Public Comments</HD> CMS continues to take steps to improve the usability of MPF to assist beneficiaries in making informed choices about their Medicare coverage. It is important that Medicare beneficiaries have the information they need to make the best choice for their health when they are exploring their plan options. Understanding which providers are in a plan's network is a vital piece for beneficiaries to make an informed choice. Provider directories allow beneficiaries and their caregivers to weigh Medicare options and decide if a plan's network meets their needs. Beneficiaries can check a provider directory to see if their existing providers are in the plan's network and which other contracted providers are available to deliver medical care. As the landscape of MA has evolved, CMS has implemented rules and made modifications to required materials, disclaimers, and website requirements to ensure that people with Medicare and the trusted individuals they rely on to aid in their decision making have the information necessary to make decisions about their Medicare options. In the December 2024 proposed rule, CMS proposed additional regulatory changes to allow the agency to leverage technological methods that streamline the beneficiary experience so that beneficiaries have the provider network information they need to make the best choice for their needs. CMS proposed to make changes that would allow MA provider directory data to be viewable on MPF for the 2026 Annual Election Period (AEP). In addition, to ensure the accuracy of the data being submitted, CMS proposed that MA organizations would be required to update the provider directory data being made available to CMS for inclusion online in MPF within 30 days of receiving information from providers of a change, and to require MA organizations to attest to the accuracy of the provider directory data being submitted. In total, CMS articulated the expectation that these proposed changes, if finalized, would result in an advancement of informed beneficiary choice and transparency benefiting people with Medicare, while also promoting robust competition within the Medicare market. Section 1851(d)(1) of the Social Security Act (the Act) states that the Secretary shall provide for activities to broadly disseminate information to current and prospective Medicare beneficiaries on MA plan coverage options to promote an active, informed selection among such options. Specifically, per section 1851(d)(2)(A)(ii) of the Act, at least 15 days before the beginning of each annual coordinated election period, the Secretary shall provide MA-eligible individuals with a list identifying the MA plans that are (or will be) available to residents of the areas in which they reside, including certain information concerning such MA plans, presented in a comparative form. This information is described in section 1851(d)(4) of the Act and includes plan benefits, premiums, service area, quality and performance indicators, and supplemental benefits. Section 1851(d)(4)(A)(vii) of the Act also sets forth that information comparing MA plan options must specifically include the extent to which an enrollee may select among in-network providers and the types of providers participating in the plan's network. In addition, section 1851(d)(7) of the Act provides that MA organizations shall provide CMS with such information about the MA organization and each MA plan that it offers, as may be required for the preparation of the information for Medicare Open Enrollment described in section 1851(d)(2)(A) of the Act. Section 1852(d)(1) of the Act requires access to services for MA enrollees and states that MA organizations offering an MA plan may select the providers from whom the benefits under the plan are provided if the MA organization complies with several conditions, including access to appropriate providers (section 1852(d)(1)(D) of the Act). Specifically, network-based MA plans must demonstrate an adequate contracted provider network that is sufficient to provide access to covered services in accordance with the access standards at section 1852 ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 82k characters. 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