CMS Proposes New Medicare Advantage Rules to Eliminate “Ghost Networks” and Protect Patients

Millions of Americans rely on Medicare Advantage plans to access doctors, hospitals, specialists, and other healthcare services. But for years, one of the biggest problems facing patients has been the accuracy of health insurance provider directories.

A patient may select a health plan because their preferred doctor appears in its network, only to discover that the doctor no longer accepts the insurance, has moved, or is not accepting new patients.

These inaccurate provider listings have become known as “ghost networks.”

On October 16, 2026, the Centers for Medicare & Medicaid Services (CMS) announced a proposed federal rule aimed at addressing this longstanding problem.

The proposal would require Medicare Advantage insurers to regularly verify provider information, measure directory accuracy, publicly disclose performance scores, and protect patients from unexpected out-of-network costs when they rely on incorrect information.

The changes would implement provisions of the Consolidated Appropriations Act of 2026, including the Requiring Enhanced and Accurate Lists of Health Providers Act, commonly called the REAL Health Providers Act.

What Are Medicare Advantage Ghost Networks?

When a health insurance company advertises its provider network, patients reasonably expect the listed doctors and facilities to be available to provide care.

Unfortunately, that is not always the case.

Provider directories may include:

• Doctors who no longer participate with the health plan.
• Providers who have retired or relocated.
• Medical offices with incorrect addresses or telephone numbers.
• Specialists who are not accepting new patients.
• Providers who appear in the network but cannot actually be accessed by members.

These inaccuracies can create the appearance that an insurance company has a much larger and more accessible provider network than it actually does.

The problem is particularly concerning for patients who require specialized services, including behavioral healthcare, psychiatry, physical therapy, and treatment for chronic medical conditions.

A 2025 report from the U.S. Department of Health and Human Services Office of Inspector General found significant limitations in behavioral health networks operated by Medicare Advantage and Medicaid managed care plans, including inactive providers listed as participating network providers.

The report also identified administrative burdens and inadequate reimbursement rates as factors affecting provider participation.

Read the "HHS Office of Inspector General report on behavioral health provider networks" (https://www.oig.hhs.gov/reports/all/2025/many-medicare-advantage-and-medicaid-managed-care-plans-have-limited-behavioral-health-provider-networks-and-inactive-providers/).

CMS Proposes Mandatory Provider Directory Verification Every 90 Days

Under the proposed regulations, Medicare Advantage organizations would be required to verify and update their provider directory information at least once every 90 days.

This would establish a more structured federal accountability framework for ensuring that information presented to Medicare beneficiaries accurately reflects available healthcare providers.

Plans would also face additional requirements concerning provider departures, directory accuracy evaluations, and reporting.

The new requirements are scheduled to begin in contract year 2028.

For healthcare providers, the changes could result in increased requests from insurance companies to confirm practice addresses, telephone numbers, participation status, and other information.

However, responsibility for complying with the proposed Medicare Advantage directory standards would rest with the health plans.

Medicare Advantage Plans Would Receive Public Accuracy Scores

Another significant element of the proposal is the introduction of publicly reported provider directory accuracy scores.

Beginning in 2028, Medicare Advantage organizations would be required to evaluate and report the accuracy of their provider directories.

Starting in 2029, CMS would publicly display accuracy scores, and Medicare Advantage organizations would be required to prominently display their scores in their provider directories.

This could introduce a new measure for consumers comparing Medicare Advantage plans.

Today, patients frequently compare plans based on premiums, copayments, prescription drug coverage, additional benefits, and provider networks.

In the future, they could also compare how accurately insurers represent their networks.

An insurer advertising thousands of participating providers may face greater public scrutiny if its directory contains inaccurate information.

A large provider network is not necessarily a useful provider network unless patients can actually access the listed providers.

New Financial Protections for Medicare Advantage Members

Perhaps one of the most important provisions concerns patients who rely on inaccurate provider directories.

Consider a Medicare beneficiary who selects a physician because the health plan's directory identifies that physician as an in-network provider.

The patient schedules an appointment, receives treatment, and later discovers that the physician was actually out of network.

Under the proposed protections, an eligible beneficiary in this situation would not be responsible for higher out-of-network cost sharing merely because the insurer supplied inaccurate network information.

The beneficiary's cost-sharing obligation would be limited according to the new statutory protections, generally to no more than the applicable in-network amount.

These protections are scheduled to take effect in 2028.

This represents an important shift toward holding insurance companies accountable for information patients rely upon when making healthcare decisions.

Behavioral Health Patients Could Benefit Significantly

Accurate provider networks are particularly important for behavioral healthcare.

Patients seeking psychiatrists, psychologists, therapists, and other mental health professionals frequently encounter difficulties identifying available providers who accept their insurance.

A directory may identify numerous behavioral health professionals, but that does not necessarily mean appointments are available.

Patients who are already struggling to access care can face additional delays when directories contain outdated or inaccurate information.

Improving directory accuracy could make it easier for patients to identify participating providers and reduce time wasted contacting unavailable professionals.

However, it is important to recognize that improving directory accuracy alone will not solve provider shortages.

If a health plan has an insufficient number of participating behavioral health providers, accurately reporting that shortage does not automatically increase access to treatment.

Insurers must also address the underlying challenges of provider recruitment, reimbursement, network development, and appointment availability.

What This Means for Healthcare Providers

The proposed regulations could have important operational implications for physician practices, outpatient clinics, behavioral health organizations, and other Medicare Advantage network participants.

Health plans will likely place greater emphasis on maintaining accurate and regularly verified provider information.

Healthcare organizations should consider reviewing their existing insurance participation records to ensure that the information maintained by health plans accurately reflects their operations.

This includes confirming:

• Participating locations and practice addresses.
• Telephone numbers and patient contact information.
• Individual provider affiliations.
• Whether providers are accepting new patients.
• Current contractual participation with individual health plans.

For multispecialty organizations, maintaining accurate records across numerous providers and locations can be particularly important.

Providers should also recognize that a contract with one insurance product does not automatically mean participation in every product offered by the same insurer.

Medicare Advantage, Medicaid managed care, commercial insurance, and other insurance products may maintain different provider networks.

The Importance of Network Accuracy for Value-Based Healthcare

Beyond patient convenience, accurate provider information is also important to the future of value-based healthcare.

Value-based payment arrangements increasingly emphasize care coordination, preventive services, timely treatment, and avoiding unnecessary emergency department visits and hospital admissions.

These models depend on patients being able to access appropriate participating providers.

When a patient cannot locate an available primary care physician or specialist, treatment may be delayed.

Delayed treatment can contribute to worsening medical conditions, avoidable emergency visits, and increased healthcare spending.

For provider networks, independent practice associations, and health plans developing value-based care arrangements, reliable provider information is therefore an important operational foundation.

Improved directory accuracy can support better referrals, care coordination, and network management.

However, directory improvements must be accompanied by sufficient provider participation and timely appointment availability to deliver meaningful improvements in access.

Additional Medicare Part D Reforms

The October 16 CMS proposal also addresses pharmacy benefit managers, commonly known as PBMs.

PBMs play an important role in administering prescription drug benefits and negotiating arrangements involving pharmaceutical manufacturers and health plans.

CMS is proposing additional requirements concerning PBM compensation, reporting, and transparency within Medicare Part D.

The proposal would place new restrictions on certain compensation arrangements and require greater disclosure of financial relationships.

Another provision would reduce generic prescription drug copayments to zero for certain low-income Medicare beneficiaries who qualify for full Medicaid benefits.

That change is scheduled to take effect in 2028.

These proposals are part of a broader effort to strengthen accountability and transparency across Medicare Advantage and Medicare Part D.

When Would the New Requirements Take Effect?

The proposed reforms would be implemented in stages.

2026: CMS releases the proposed regulations and opens the federal public comment process.

2028: New Medicare Advantage provider directory verification, accuracy reporting, and patient cost-sharing protections are scheduled to take effect.

2029: Public provider directory accuracy scores would become available through CMS and Medicare Advantage plan directories.

The October 16 announcement is a proposed rule, not a final regulation. CMS may revise implementation details following the public comment process.

What Medicare Beneficiaries Should Do Today

Medicare's annual open enrollment period began October 15, 2026, and continues through December 7, 2026.

Beneficiaries selecting coverage for 2027 should not assume that every provider appearing in an insurance directory is necessarily available.

Before enrolling in a Medicare Advantage plan, patients should contact their preferred doctors and confirm that they participate in the specific plan being considered.

Patients should also verify that their doctors are accepting new patients and that the hospitals, specialists, and other services they expect to use are covered.

These steps remain important while the new federal directory requirements are being implemented.

Marton Care's Perspective

At Marton Care, we believe healthcare coverage must mean more than simply possessing an insurance identification card.

The purpose of health insurance is to provide access to healthcare. A provider network should reflect providers who are actually available to deliver those services.

Accurate directories, sufficient reimbursement, accessible appointments, and meaningful provider participation are all essential components of a functioning healthcare system.

The proposed CMS reforms represent an important effort to improve transparency and accountability.

Nevertheless, true network adequacy must be measured not only by how many providers appear on an insurance company's website, but by how many patients can actually receive the care they need.

As healthcare increasingly moves toward integrated delivery systems, coordinated provider networks, and value-based payment models, reliable information and meaningful access will become even more important.

Patients deserve accurate information. Providers deserve fair and transparent network relationships. And health plans must be accountable for the networks they advertise.

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Sources

1. "CMS — October 16, 2026: Proposed Reforms to Strengthen Transparency and Affordability in Medicare Advantage and Part D" (https://www.cms.gov/newsroom/press-releases/cms-proposes-reforms-strengthen-transparency-affordability-medicare-advantage-part-d)

2. "CMS — Official Fact Sheet on the Proposed Medicare Advantage and Part D Rule" (https://www.cms.gov/newsroom/fact-sheets/medicare-program-implementation-sections-6219-6220-6224-consolidated-appropriations-act-2026-cms)

3. "HHS Office of Inspector General — Behavioral Health Provider Networks and Inactive Providers" (https://www.oig.hhs.gov/reports/all/2025/many-medicare-advantage-and-medicaid-managed-care-plans-have-limited-behavioral-health-provider-networks-and-inactive-providers/)

4. "KFF — How to Verify Whether a Doctor Participates in a Medicare Advantage Network" (https://www.kff.org/faqs/medicare-open-enrollment-faqs/medicare-advantage/how-can-i-find-out-if-my-doctor-is-in-a-medicare-advantage-plan-network/)