CMS's Proposed Ghost Network Rule: What Agents Need to Know (It's Not Final)
If you've had a client pick a plan because their doctor was "in network," then find out the listing was wrong, you know what a ghost network costs. CMS just proposed a fix. Key word: proposed.
What CMS proposed
On Oct 16, per the CMS press release and fact sheet, the proposed rule would:
Require MA plans to verify provider directory information at least every 90 days, starting in contract year 2028.
Cap cost sharing at in-network levels for a member who relied on an inaccurate "in-network" directory listing, starting in 2028.
Have CMS publicly display directory accuracy scores starting in contract year 2029.
Separately, lower the generic drug copay for the lowest-income full dual eligibles from $1 to $0 in 2028.
What it is not
It's not final. It doesn't change anything for 2027 plans or this AEP. A proposed rule goes through public comment, and CMS can change it before it's finalized. Don't tell a client a wrong directory listing is covered at in-network cost today because of this rule.
What to do this AEP
Keep verifying the old way. Call the doctor's office and ask about the exact plan by name, not just the carrier.
Document it. Note who you talked to and when.
Set expectations. If a client asks about "the new directory rule," tell them it's proposed for 2028 and later, not in effect.
Watch for the final rule. If it's finalized, accuracy scores could become a plan comparison point starting with 2029 plans.
For more on how to approach plan comparisons this season, see our AEP 2027 playbook and our breakdown of 2027 star ratings.
Get the free Medicare Bible
Rules change, and proposals aren't rules. Brock puts out tons of resources like these, and the Medicare Bible keeps your fundamentals straight while the rulemaking plays out. Download the free Medicare Bible.
Related reading:
FAQ
Is the CMS ghost network rule final?
No. CMS proposed it on Oct 16. It's open for comment and could change before it's finalized.
When would the directory requirements start?
As proposed, 90-day directory verification and in-network cost sharing protection would start in 2028, and public accuracy scores in 2029.
Does this change anything for 2027 plans?
No. Keep verifying providers directly with the office for the exact plan.
