联邦医保提议新规：Medicare Advantage计划须每90天核验医生目录，药房福利管理人收费须公开报告
美国联邦医疗保险和医疗补助服务中心（CMS）发布拟议规则，拟要求 Medicare Advantage（医疗保险优势计划）大幅提高其医生与医疗机构目录的准确性，并对处方药计划（Part D）中的药房福利管理人（PBM）设立收费透明与报告要求，同时加强对低收入受益人的费用保障。拟议规则适用于2028合同年度，落实《2026年综合拨款法》第6219、6220与6224条，在《联邦公报》刊登后将有60天公众评论期。
在目录准确性方面，CMS 提议要求各计划至少每90天核实并更新一次服务提供者目录信息，并向 CMS 报告一个准确性评分；该评分还须醒目地展示在计划面向公众的目录页面上，让受益人在挑选计划时能比较各家目录的可靠程度。
对参保人的费用保护方面，CMS 提议：若参保人依据目录中不准确的信息就医、结果接受了网络外提供者的服务，其应付费用不得高于网络内的自付标准，以避免因目录错误产生意外账单与就医中断。
在药价方面，CMS 提议要求药房福利管理人每年向计划主办方与 CMS 报告其薪酬与成本绩效，并要求付给 PBM 的报酬反映其所提供服务的公平市场价值，而不是与药品价格挂钩，以抑制推高药价的做法。CMS 署长 Mehmet Oz 表示，该机构一直致力于改善整个医疗体系中服务提供者目录的数据连通性与准确性，本次提议将让 Medicare Advantage 与 Part D 参保人获得更可靠的信息与更强的财务保障。CMS 还表示，预计今年秋季晚些时候再发布一项针对 C、D 部分的政策与技术调整拟议规则。
CMS Proposes Medicare Advantage Directory Accuracy Rule: Plans Must Verify Provider Listings Every 90 Days and PBMs Must Disclose Pay
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would improve the accuracy of provider directories for Medicare Advantage plans, establish transparency and compensation requirements for pharmacy benefit managers (PBMs) in Part D, and deliver enhanced cost-saving protections for low-income Medicare beneficiaries. The proposed changes, for contract year 2028, implement sections 6219, 6220, and 6224 of the Consolidated Appropriations Act of 2026, and will be open for public comment for 60 days following publication in the Federal Register.
On directory accuracy, CMS proposes that plans be required to verify and update their provider directory information at least every 90 days and report an accuracy score to CMS. The scores would be prominently displayed on the plans' public-facing directories, empowering beneficiaries to compare how reliable each plan's listings are when choosing coverage.
On cost protection, CMS proposes that enrollees who rely on inaccurate directory listings that led them to receive care from an out-of-network provider would pay no more than their in-network cost-sharing amount, protecting them from unexpected costs and care disruptions.
On drug costs, CMS proposes reporting requirements under which PBMs would report their compensation and cost performance to plan sponsors and CMS on an annual basis, and a requirement that PBM payments reflect fair market value for services provided rather than drug costs, aimed at curbing practices that drive up drug prices. CMS Administrator Mehmet Oz said the agency has been working to improve data connectivity and accuracy in provider directories across the healthcare system, and that the proposals would give Medicare Advantage and Part D enrollees more reliable information, stronger financial protections, and greater confidence in both programs. CMS anticipates releasing another proposed rule on policy and technical changes for Parts C and D later this fall.
来源：GSM·美国（原文链接）
图片来源：美国联邦医疗保险（Medicare）卡样本（资料图）。美国联邦医疗保险和医疗补助服务中心（CMS），公共领域，经 Wikimedia Commons。 / A sample U.S. Medicare card (file photo). Centers for Medicare & Medicaid Services (CMS), public domain, via Wikimedia Commons.
