Medicare 2026

CMS Proposes $0 Generic Copays for Low-Income Dual Eligibles and Tougher 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 carry out several parts of the Consolidated Appropriations Act, 2026, which Congress passed and the President signed on February 3, 2026. The proposal has two headline features that touch everyday Medicare: a $0 copay for generic drugs for certain low-income enrollees starting in 2028, and new accuracy rules for Medicare Advantage provider directories, also starting in 2028. CMS is also proposing new transparency rules for pharmacy benefit managers in Part D.

This is a proposal, not a final rule. To be assured consideration, comments must be received by 5 p.m. Eastern Standard Time on December 15, 2026.

What's in the drug-cost piece

Section 6219 of the new law sets the Part D copay for generic drugs at $0 for plan years beginning on or after January 1, 2028, for people who have both Medicare and full Medicaid coverage and whose incomes are at or below 100% of the federal poverty level. CMS's proposed rule would update the regulations to match.

For context, in plan year 2026 the same group pays up to $1.60 for generics and $4.90 for other covered Part D drugs, with no deductible. The law does not change the yearly inflation adjustment for non-generic drugs — those cost-sharing amounts can still move with inflation each year — but the generic copay would be fixed at $0 starting in 2028. CMS estimates about 6 million enrollees would see the generic change.

What's in the provider-directory piece

The REAL Health Providers Act (section 6220) adds several directory requirements for network-based Medicare Advantage plans, beginning in plan year 2028:

• The plan must verify each provider's directory information at least once every 90 days (hospitals and certain facilities would be verified at a frequency CMS sets, but at least every 12 months).
• If the plan cannot verify a provider's information, it must flag that entry as possibly out of date.
• When a provider leaves the network, the plan must remove them within 5 business days of making that determination.

The law also creates a consumer protection: if you are enrolled in a network-based Medicare Advantage plan and you get a covered service from a provider listed in the plan's directory on the date you made the appointment, but it turns out that provider is not actually in the network, the plan must limit your cost sharing to the lesser of the in-network amount or the amount that would normally apply. Plans must tell enrollees about this protection.

CMS proposes several details that could still change in the final rule:

• Plans would apply the protection automatically when they know or reasonably should know it applies.
• Enrollees or their representatives could also request it verbally or in writing; the request would be handled through the plan's organization determination and appeals process.
• The earliest date the appointment was scheduled would count, even if the appointment was later rescheduled.
• If needed documentation cannot be obtained, the plan should resolve the question in the enrollee's favor.

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. The proposed rule would also add new compensation, reporting and transparency requirements for pharmacy benefit managers in Part D under section 6224.

How to comment

You can submit a comment one way — not multiple ways:

• Electronically at regulations.gov under docket CMS-2026-2533.
• By regular mail.
• By express or overnight mail.

CMS does not accept comments by fax. Keep in mind that comments are posted publicly, including any personal information they contain.

Where this fits in the bigger picture

Even as these proposals move through the comment process, the current year's choices are in front of you. Annual Enrollment for 2027 runs October 15 – December 7, 2026, with choices taking effect January 1, 2027. For 2027, the Part D out-of-pocket cap rises to $2,400 (up from $2,100 in 2026), the maximum Part D deductible any plan may charge is $700, and the Part D base beneficiary premium — a national figure used to calculate the late-enrollment penalty — is $41.33. Actual plan premiums are set plan by plan. Social Security announced a 3.6% cost-of-living adjustment for benefits payable beginning January 2027. The 2027 Part B standard premium and deductible, and the 2027 IRMAA income brackets, have not yet been announced; CMS typically releases them in the fall.

A few reminders for people with Medicaid or Extra Help: since 2025, you have a monthly Special Enrollment Period to move to Original Medicare with a stand-alone Part D plan, or to switch stand-alone Part D plans. If you are a full-benefit dual eligible, you can join an integrated Dual Eligible Special Needs Plan (D-SNP) in any month.

As you weigh coverage, remember that Medicare Advantage and Original Medicare (often paired with a Medigap policy and a stand-alone Part D plan) involve different trade-offs — network rules, cost sharing, extra benefits, out-of-pocket exposure and paperwork all look different. There is no one-size-fits-all answer; the right fit depends on your doctors, your prescriptions and your budget.

For official information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), available 24 hours a day, seven days a week. This article is educational only and is not affiliated with any government agency.