Medicare 2026

CMS Proposes $0 Generic Copays for Some Dual Eligibles and Stricter Provider Directory Rules — Public Comments Due December 15

On October 20, 2026, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule (file code CMS-4214-P, 91 FR 66408) that would put several new consumer protections into Medicare's rulebook. It's a proposal — not a final rule — and the public has until 5 p.m. Eastern on December 15, 2026, to weigh in. Here's what the rule would do, who it would affect, and how to comment.

What the proposed rule would change

The rule carries out three sections of the Consolidated Appropriations Act, 2026 (Public Law 119-75, enacted February 3, 2026).

$0 generic copays for certain dual-eligible enrollees (Section 6219). Today, in plan year 2026, full-benefit dual-eligible people with incomes at or below 100% of the federal poverty level pay up to $1.60 for generic drugs and $4.90 for other covered Part D drugs, with no deductible. Under the new law, starting with plan years on or after January 1, 2028, the generic copay for this group drops to $0. The copay for non-generics would continue to be adjusted for inflation each year as under current law. CMS estimates about 6 million enrollees would benefit from the $0 generic copay. The proposed rule simply makes the regulations match the statute.

More accurate Medicare Advantage provider directories (Section 6220, the REAL Health Providers Act). Beginning in plan year 2028, a Medicare Advantage organization offering a network-based plan would have to:

• Verify each provider's directory information at least once every 90 days (hospitals and certain other facilities at a frequency CMS sets, but at least once every 12 months).
• Flag any provider whose information can't be verified as possibly out of date.
• Remove a provider within 5 business days of determining the provider has left the network.

A cost-sharing safety net when directories are wrong. Also starting in plan year 2028, if you're in a network-based Medicare Advantage plan and you get a covered service from a provider who was listed in the directory on the date you booked the appointment — but who turns out to be out of network — your plan would have to charge you the lesser of the in-network amount or what would otherwise apply. Plans would be required to tell enrollees about this protection.

CMS proposes several details: plans would apply the protection automatically when they know or reasonably should know it applies; enrollees (or their representatives) could also ask verbally or in writing, handled as an organization determination or reconsideration; the earliest date the appointment was scheduled would count even if it was later rescheduled; and if documents can't be obtained, the protection would be applied in the enrollee's favor. Those details are proposals and could change in the final rule.

Public directory accuracy scores. Starting in 2029, CMS would publicly post provider directory accuracy scores, and Medicare Advantage organizations would have to display those scores prominently in their directories.

PBM transparency in Part D (Section 6224). The rule also proposes new compensation, reporting, and transparency requirements for pharmacy benefit managers that work with Part D plans.

How to comment

To be assured consideration, comments must be received by 5 p.m. Eastern Standard Time on December 15, 2026. You can submit:

• Electronically at regulations.gov (docket CMS-2026-3533), or
• By regular mail, or
• By express or overnight mail.

Use only one method. CMS does not accept comments by fax. Note that comments — including any personal information in them — are posted publicly. (The docket number was corrected in a November 6, 2026 notice, CMS-4214-CN, after a typo in the original rule's address section.)

How this fits with the rest of Medicare in 2027

A few program-level items that are already set for 2027:

• The Part D out-of-pocket cap rises to $2,400 (it's $2,100 in 2026).
• The maximum Part D deductible any plan may charge is $700.
• The Part D base beneficiary premium, used in the late-enrollment penalty calculation, is $41.33. Actual plan premiums are set plan by plan.
• Social Security announced a 3.6% cost-of-living adjustment for benefits payable starting January 2027.

The 2027 Part B standard premium and deductible, and the 2027 IRMAA income brackets, had not been announced at the time of this writing. CMS typically releases those figures in the fall.

Other ways to make a change

Annual Enrollment runs October 15 – December 7, 2026 for coverage that starts January 1, 2027. If you have Medicaid or qualify for the Extra Help program, you also have a monthly Special Enrollment Period that lets you move to Original Medicare paired with a stand-alone Part D plan, or switch stand-alone Part D plans. Full-benefit dual-eligible people can enroll in an integrated Dual Eligible Special Needs Plan (D-SNP) in any month.

Choosing coverage: a neutral comparison

Many people weigh Medicare Advantage against Original Medicare with a Medigap policy and a stand-alone Part D plan. Medicare Advantage plans typically bundle medical and drug coverage and may include extra benefits, but they generally use provider networks and prior-authorization rules (which is why the directory protections in this rule matter). Original Medicare with Medigap lets you see any provider who accepts Medicare and tends to have more predictable cost sharing when paired with a supplement, but it's separate from drug coverage and Medigap underwriting rules vary. Neither option is "best" — it depends on your providers, medications, budget, and travel needs.

Where to learn more

For personalized information about your situation, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, available 24/7. For the proposed rule itself, see regulations.gov under docket CMS-2026-3533.