CMS proposes new regulations to eliminate ‘ghost networks’ and improve PBM transparency

On Friday, the Centers for Medicare & Medicaid Services (CMS) released a regulatory framework for how it intends to enforce recent healthcare reforms enacted by Congress in February as part of a 2026 consolidated appropriations package.

The proposed rule looks to tackle “ghost networks” and improve pharmacy benefit manager (PBM) accountability, in addition to other changes related to prescription drug copayments. The reforms, the agency said in a statement, will benefit Americans who rely on Medicare Advantage and the Medicare Part D pharmaceutical subsidy program.

CMS said the proposed rule would “improve the accuracy of provider directories” and establish rules for PBMs aimed at improving “transparency and compensation requirements” for PBMs, all with the aim of implementing cost-savings guarantees for Medicare enrollees.

“CMS has been working to improve data connectivity and accuracy in provider directories across the healthcare system,” CMS Administrator Mehmet Oz, MD, stated. “The actions we are proposing today will give Medicare Advantage and Part D enrollees more reliable information, stronger financial protections, and greater confidence in both programs.”

Regularly updated directories

Looking at “ghost networks”—an ongoing issue where specialty and primary care providers are listed as in-network for a plan when they are not—CMS has proposed a solution whereby insurance companies will be required to verify and update their directories every 90 days, in an effort to ensure patients have up-to-date information.

As part of enforcement, the agency said accuracy scores will need to be reported to the federal government after every update. CMS said these ratings would also be "prominently displayed” on all public-facing directories released by health plans, so beneficiaries can get a good idea of how reliably accurate in-network determinations are over time.

“This proposal protects beneficiaries from unexpected costs and care disruptions that can occur when they rely on inaccurate directory information to find an in-network provider,” the agency wrote in its statement. “By codifying these standards, CMS is strengthening enrollee protections and increasing transparency across the Medicare Advantage program.”

CMS is also proposing certain protections for consumers who get inaccurate information from a directory and are left with a surprise out-of-network bill. In such cases, patients will only be required to pay the in-network cost-sharing amount, the agency said—assuming the proposal is finalized after a public comment period.

In many cases, ghost networks will make it seem as if certain healthcare services, such as behavioral health, are covered and more readily available than they actually are. The agency said its regulatory changes are designed to ensure patients are able to find the care they need without fear they will be paying more than expected for services.