Dive Brief:
Seniors shopping between Medicare Advantage plans will soon have clearer data about payers’ provider networks under a rule the CMS finalized Thursday.
Regulators are requiring MA plans to directly disclose their provider directories on Medicare Plan Finder for 2027 open enrollment, in a bid to help seniors make more informed decisions about which plan best meets their needs.
The policy was originally proposed by the Biden administration in November, but comes amid a larger push for more transparency around payers’ provider networks from health officials in the Trump regime. A separate CMS rule will populate Plan Finder with provider directory data from a third-party vendor for 2026 open enrollment this fall.
Dive Insight:
Regulators in the Biden administration drafted a number of changes to the MA program on its way out of the door last fall. However, the Trump administration’s first MA policy rule in April largely ignored the proposals of its predecessors. Regulators elected not to finalize limits on the use of artificial intelligence in prior authorization and MA plans’ marketing practices, among other suggested policy tweaks.
But the Trump administration has now finalized one element of the rule meant to increase beneficiaries’ access to provider data. In a memo to insurers, the CMS said it was issuing the provider directory requirement through a separate final rule to give MA plans “maximum lead time” to prepare to integrate their directories into Medicare Plan Finder ahead of open enrollment for 2027.
Plan Finder is an online portal where people interested in signing up for Medicare can explore different coverage options. It includes information about benefits, premiums, deductibles and quality ratings, but doesn’t currently include information about contracted provider networks.
But now, the CMS is requiring that MA plans submit their provider directory data to be published online; update their provider directory information within 30 days of becoming aware of any changes; and attest at least once a year that their provider directory information is accurate.
“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,” regulators wrote in the final rule.
The CMS has been beefing up Plan Finder, notifying insurers in August that it planned to incorporate provider networks into the portal through a partnership with an external data vendor, along with adding more data about supplemental benefits and prescription drug pricing.
The agency is also working to develop a national provider directory, top healthcare regulators said this summer, though they’ve released few details. Creating a single, unified provider directory has been a dream of multiple administrations, but efforts have failed to reach traction amid technological hurdles, bureaucratic red tape and opposition from insurers.
The comprehensiveness of a plan’s provider network should be a key factor in consumers selecting that coverage. But insurers’ provider directors are frequently inaccurate and outdated, giving rise to what’s known as “ghost networks” — when doctors are listed in a plans’ directory but aren’t actually available for patients.
It’s a widespread issue: Only one-third of provider listings contacted by Senate subcommittee staffers in 2023 were accurate. Though the investigation had a small sample size, it backs up other research finding a meaningful number of providers on plan directories are not actually in network. One study also from 2023 found upwards of 80% of provider listings contained inconsistencies.
Health plans maintain that keeping their provider lists current is next to impossible, due to frequent changes in information. But consumers, regulators and lawmakers are increasingly pushing back: Centene, for example, is currently facing a lawsuit from the family of a policyholder who died after he was unable to access providers that ostensibly were covered by the payer.
