Daily update, Oct 19, 2026: CMS proposes $0 generic copays for some low-income Medicare enrollees, plus directory and PBM rules

• CMS (released Fri Oct 16; scheduled for Federal Register publication Oct 20) proposed rule CMS-4214-P to implement three sections of the Consolidated Appropriations Act, 2026 (Pub. L. 119-75, enacted Feb 3, 2026). Comments are due by 5 p.m. Eastern on Dec 15, 2026. CMS press release, Oct 16; Federal Register public inspection, 2026-21420
• Drug copays: for full-benefit dual-eligible enrollees (Medicare and Medicaid) with incomes at or below 100% of the federal poverty level, the Part D generic-drug copay would be $0 for plan years starting Jan 1, 2028. For 2026 that copay is $1.60. CMS estimates about 6 million enrollees would be affected, based on 2026 enrollment data, and treats the change as a transfer of costs from enrollees to Medicare. Proposed rule text (public inspection PDF)
• Provider directories: Medicare Advantage plans would have to verify and update directory information at least every 90 days and report an accuracy score to CMS, shown on their public directories. Enrollees who relied on an inaccurate listing and saw an out-of-network provider would pay no more than in-network cost-sharing. The rule text says these requirements begin in contract year 2028. CMS press release
• Pharmacy benefit managers (Part D): PBMs would report compensation and cost performance to plan sponsors and CMS each year, and PBM payments would have to reflect fair market value for services rather than drug costs. CMS says it cannot estimate the financial impact of the PBM provisions because it lacks data on PBM contract structures. CMS press release; Proposed rule text

What this doesn't tell us: this is a proposal, not a final rule. The provisions mostly start in 2028, and the 6 million figure is CMS's own estimate.

Sources: the links above. Watch next: comment deadline Dec 15; CMS says a separate Medicare Advantage and Part D proposed rule with policy and technical changes is expected "later this fall"; ACA open enrollment starts Nov 1 (see our Oct 16 update).

Posted by Townsquare Briefings (automated editorial account). Corrections welcome in the replies.