The Centers for Medicare & Medicaid Services (CMS) has proposed a rule to carry out three provisions Congress added to Medicare in the Consolidated Appropriations Act, 2026 (CAA): a lower drug copay for the lowest-income enrollees, new accuracy requirements for Medicare Advantage provider directories, and new limits on what pharmacy benefit managers (PBMs) can be paid. The rule is on public inspection and is scheduled to be published in the Federal Register on October 20, 2026.
Part D: a $1 copay would drop to $0 in 2028
Section 6219 of the CAA amends the Medicare statute to reduce the generic-drug copayment from $1 to $0 for "full-benefit dual eligible" individuals — those who qualify for both Medicare and full Medicaid benefits — "with incomes that do not exceed 100 percent of the FPL," the Federal Poverty Level. It applies "for plan years beginning on or after January 1, 2028." CMS proposes to amend its own regulation to match, and calls that proposal "a conforming change to existing regulatory text" that would not alter eligibility, the subsidy structure or any other cost-sharing parameter. Until 2028 the generic copayment keeps its annual inflation adjustment; for plan year 2026 it is $1.60. CMS says it is not proposing changes for brand-name or other covered Part D drugs, whose copayments would keep being adjusted annually. CMS estimates about 6 million enrollees would be affected, based on 2026 CMS enrollment data.
Medicare Advantage: a wrong directory listing would mean the lower cost sharing
Section 6220, the REAL Health Providers Act, amends the Medicare statute to establish new provider-directory accuracy and accountability requirements for Medicare Advantage organizations, "effective January 1, 2028, which is the beginning of contract year 2028." They would reach what CMS proposes to define as a "specified MA plan," which CMS says covers all types of MA plans except non-network regional PPOs that meet access requirements substantially through another authority instead of written contracts, and would not apply to Program of All-Inclusive Care for the Elderly plans. One requirement is a cost-sharing protection for enrollees who rely on incorrect directory information: if a provider is in such a plan's online directory on the date an enrollee makes an appointment, but it is determined that the provider is no longer in-network when the item or service is furnished, the organization must limit enrollee cost sharing to the lesser of the in-network or otherwise applicable cost sharing amount. CMS proposes how an enrollee claims it, and says that if the organization cannot obtain the documentation it needs — from provider documentation, attestation, or a provider directory archive — then "the protections would be applied in the enrollee's favor" under proposed section 422.124(f). The organization would also have to apply the protections without requiring an enrollee request when it "knows or reasonably should know" they apply. From 2029 the statute requires the Secretary to post those accuracy scores in a machine-readable file on an internet website maintained by CMS, and requires a specified MA plan's score to be "listed prominently" on the plan's provider directory; CMS proposes to codify both.
Pharmacy benefit managers: pay would be tied to service, not drug price
Section 6224 generally requires that PBMs and any affiliates of such PBMs not derive any remuneration with respect to any services provided on behalf of any entity or individual, in connection with the utilization of covered Part D drugs, other than "bona fide service fees." Those fees must be flat dollar amounts, reflective of fair market value as specified by the Secretary through notice and comment rulemaking, for an itemized service, and they "may not be contingent on the amount of rebates, discounts, fees, or other direct or indirect remuneration; drug price; coverage or formulary placement"; the list closes with "any other amounts or methodologies prohibited by the Secretary." There are exceptions, including certain incentive payments, manufacturer rebates fully passed through to a Part D plan sponsor and compliant with the program's rules on direct and indirect remuneration, and flat dispensing fees. Beginning with contract year 2028 a Part D plan sponsor must have a written agreement with any PBM acting on its behalf containing these requirements, and PBMs must report to the plan sponsor and the Secretary "not later than July 1 of each year, beginning in 2028," with information on the previous plan year. Remuneration received in violation must be disgorged to the plan sponsor and, CMS proposes, on to CMS for deposit into the Federal Supplementary Medical Insurance Trust Fund.
The dates
This is a public-inspection copy; the Federal Register has not yet published it. The document's own DATES paragraph reads: "To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. Eastern Standard Time on December 15, 2026." That date is printed in the document, not computed by this desk — CMS knows its publication date in advance, so it prints a real date rather than the bracketed placeholder an inspection copy often carries. The three statutory provisions apply beginning with plan or contract year 2028, which begins January 1, 2028, except the PBM report, first due July 1, 2028, and the accuracy-score posting and display, which begin in 2029.
What the rule does not say
This is a proposal, not a final rule; nothing changes yet. The CAA was enacted into law on February 3, 2026, so the three statutory provisions already exist; what is open here is the regulation that would implement them. CMS says the financial impact of the PBM proposal "is not able to be estimated due to the lack of data on PBM contract structures and the difference between current fee levels and the proposed fair market value." It does report that the Congressional Budget Office estimated the statutory remuneration provision would reduce federal direct spending by approximately $444 million over the 2026-2035 period.