CMS proposed-rule announcement and fact sheet, October 16; Medicare.gov plan guidance
A listing in a health plan's directory can send a patient to the wrong address, a disconnected phone, or a clinic outside the network. CMS now proposes a more regular check on those listings, with financial protection for Medicare Advantage enrollees who rely on inaccurate information.
In brief
- Plans would verify and update directory information at least every 90 days.
- Directory requirements begin in contract year 2028; public accuracy-score display follows in 2029.
- The October 16 release is a proposal implementing a law enacted in February.
A directory would have to answer for its errors
Under the October 16 proposal, Medicare Advantage plans would verify and update provider information at least every 90 days and report a directory accuracy score to CMS. Enrollees whose reliance on an inaccurate listing leads them to an out-of-network provider would owe no more than the in-network cost-sharing amount.
For occupational therapy, the practical concern begins before the evaluation. A referral can stall while a patient or family searches for a clinic that actually participates in the plan. A more reliable directory could reduce that friction, although the proposal does not establish how much faster people would reach OT care.
The dates belong to 2028 and 2029
The underlying REAL Health Providers Act was enacted in the Consolidated Appropriations Act on February 3. CMS's new proposal, CMS-4214-P, sets out implementing regulations. Its fact sheet places directory verification, maintenance, annual accuracy analysis and reporting, and enrollee cost-sharing protections in contract year 2028. Public display of accuracy scores by CMS and plans follows in contract year 2029, including a machine-readable CMS format.
CMS says comments will be accepted for 60 days after Federal Register publication. Practices considering comments could describe the specific errors that obstruct referrals and explain how they learn whether a submitted correction has reached the public directory. Those are suggested topics for feedback; the proposed requirements are directed at Medicare Advantage organizations.
Check the listing and the visit separately
A useful clinic check today is to compare each plan's public listing with the information staff give callers. Review the practice location, phone number and individual clinician entries. Keep a dated record of correction requests and check the listing again afterward. These are practical office steps, separate from the proposed federal standards.
Patients still need answers about the particular plan and visit. Medicare.gov's existing guidance says HMO members generally use network providers, with specified exceptions, and must follow applicable prior-approval rules. A directory entry alone leaves questions about authorization and the patient's therapy costs unresolved. A clinic can help by confirming those details before scheduling and giving the patient a clear contact when the plan's answer conflicts with the listing.