Current status is Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.

119th CONGRESS

1st Session

H. R. 5281

1. Short title
2. Provider directory requirements under Medicare Advantage

1. Short title

This Act may be cited as the "Requiring Enhanced and Accurate Lists of Health Providers Act" or the "REAL Health Providers Act".

2. Provider directory requirements under Medicare Advantage

(a) In general - Section 1852(c) of the Social Security Act (42 U.S.C. 1395w–22(c)) is amended—

(1) - in paragraph (1)(C)—

(A) - by striking "plan, and any" and inserting "plan, any"; and

(B) - by inserting the following before the period: ", and, in the case of a specified MA plan (as defined in paragraph (3)(C)), for plan year 2028 and subsequent plan years, the information described in paragraph (3)(B)"; and

(2) Provider directory accuracy - by adding at the end the following new paragraph:

(3) Provider directory accuracy -

(A) In general - For plan year 2028 and subsequent plan years, each MA organization offering a specified MA plan (as defined in subparagraph (C)) shall, for each such plan offered by the organization—

(i) - maintain, on a publicly available internet website, an accurate provider directory that includes the information described in subparagraph (B);

(ii) - not less frequently than once every 90 days (or, in the case of a hospital or any other facility determined appropriate by the Secretary, at a lesser frequency specified by the Secretary but in no case less frequently than once every 12 months), verify the provider directory information of each provider listed in such directory and, if applicable, update such provider directory information;

(iii) - if the organization is unable to verify such information with respect to a provider, include in such directory an indication that the information of such provider may not be up to date; and

(iv) - remove a provider from such directory within 5 business days if the organization determines that the provider is no longer a provider participating in the network of such plan.

(B) Provider directory information - The information described in this subparagraph is information enrollees may need to access covered benefits from a provider with which such organization offering such plan has an agreement for furnishing items and services covered under such plan such as name, specialty, contact information, primary office or facility address, whether the provider is accepting new patients, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.

(i) - a network-based plan (as defined in subsection (d)(5)(C)); or

(ii) - a Medicare Advantage private fee-for-service plan (as defined in section 1859(b)(2)) that meets the access standards under subsection (d)(4), in whole or in part, through entering into contracts or agreements as provided for under subparagraph (B) of such subsection.

(b) Accountability for provider directory accuracy -

(1) Cost Sharing for Services Furnished Based on Reliance on Incorrect Provider directory Information - Section 1852(d) of the Social Security Act (42 U.S.C. 1395w–22(d)) is amended—

(A) - in paragraph (1)(C)—

(i) - in clause (ii), by striking "or" at the end;

(ii) - in clause (iii), by striking the semicolon at the end and inserting ", or"; and

(iii) - by adding at the end the following new clause:

(iv) - the services are furnished by a provider that is not participating in the network of a specified MA plan (as defined in subsection (c)(3)(C)) but is listed in the provider directory of such plan on the date on which the appointment is made, as described in paragraph (7)(A);

(B) Cost sharing for services furnished based on reliance on incorrect provider directory information - by adding at the end the following new paragraph:

(7) Cost sharing for services furnished based on reliance on incorrect provider directory information -

(A) In general - For plan year 2028 and subsequent plan years, if an enrollee is furnished an item or service by a provider that is not participating in the network of a specified MA plan (as defined in subsection (c)(3)(C)) but is listed in the provider directory of such plan (as required to be provided to an enrollee pursuant to subsection (c)(1)(C)) on the date on which the appointment is made, and if such item or service would otherwise be covered under such plan if furnished by a provider that is participating in the network of such plan, the MA organization offering such plan shall ensure that the enrollee is only responsible for the lesser of—

(i) - the amount of cost sharing that would apply if such provider had been participating in the network of such plan; or

(ii) - the amount of cost sharing that would otherwise apply (without regard to this subparagraph).

(B) Notification requirement - For plan year 2028 and subsequent plan years, each MA organization that offers a specified MA plan shall—

(i) - notify enrollees of their cost-sharing protections under this paragraph and make such notifications, to the extent practicable, by not later than the first day of an annual, coordinated election period under section 1851(e)(3) with respect to a year;

(ii) - include information regarding such cost-sharing protections in the provider directory of each specified MA plan offered by the MA organization; and

(iii) - notify enrollees of their cost-sharing protections under this paragraph in an explanation of benefits.

(2) Required provider directory accuracy analysis and reports -

(A) In general - Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:

(6) Provider directory accuracy analysis and reports -

(A) In general - Beginning with plan years beginning on or after January 1, 2028, subject to subparagraph (C), a contract under this section with an MA organization shall require the organization, for each specified MA plan (as defined in section 1852(c)(3)(C)) offered by the organization to annually do the following:

(i) - Conduct an analysis estimating the accuracy of the provider directory information of such plan using a random sample of providers included in such provider directory as follows:

(I) - Such a random sample shall include a random sample of each specialty of providers with a high inaccuracy rate of provider directory information relative to other specialties of providers, as determined by the Secretary.

(II) - For purposes of subclause (I), one type of specialty may be providers specializing in mental health or substance use disorder treatment.

(ii) - Submit to the Secretary a report containing the results of the analysis conducted under clause (i), including an accuracy score for such provider directory information (as determined using a plan verification method specified by the Secretary under subparagraph (B)(i)).

(B) Determination of accuracy score -

(i) In general - The Secretary shall specify plan verification methods, such as using telephonic verification or other approaches using data sources maintained by an MA organization or using publicly available data sets, that MA organizations may use for estimating accuracy scores of the provider directory information of specified MA plans offered by such organizations.

(ii) Accuracy score methodology - With respect to each such method specified by the Secretary as described in clause (i), the Secretary shall specify a methodology for MA organizations to use in estimating such accuracy scores. Each such methodology shall take into account the administrative burden on plans and providers and the relative importance of certain provider directory information on enrollee ability to access care.

(C) Exception - The Secretary may waive the requirements of this paragraph in the case of a specified MA plan with low enrollment (as defined by the Secretary).

(D) Transparency - Beginning with plan years beginning on or after January 1, 2029, the Secretary shall post accuracy scores (as reported under subparagraph (A)(ii)), in a machine readable file, on the internet website of the Centers for Medicare & Medicaid Services.

(B) Provision of information to beneficiaries - Section 1851(d)(4) of the Social Security Act (42 U.S.C. 1395w–21(d)(4)) is amended by adding at the end the following new subparagraph:

(F) Provider Directory - Beginning with plan years beginning on or after January 1, 2029, the accuracy score of the plan’s provider directory (as reported under section 1857(e)(6)(A)(ii)) listed prominently on the plan’s provider directory.

(C) Funding - In addition to amounts otherwise available, there is appropriated to the Centers for Medicare & Medicaid Services Program Management Account, out of any money in the Treasury not otherwise appropriated, $4,000,000 for fiscal year 2026, to remain available until expended, to carry out the amendments made by this paragraph.

(3) GAO study and report -

(A) Analysis - The Comptroller General of the United States (in this paragraph referred to as the "Comptroller General") shall conduct a study of the implementation of the amendments made by paragraphs (1) and (2). To the extent data are available and reliable, such study shall include an analysis of—

(i) - the use of cost-sharing protections required under section 1852(d)(7)(A) of the Social Security Act, as added by paragraph (1);

(ii) - the trends in provider directory information accuracy scores under section 1857(e)(6)(A)(ii) of the Social Security Act (as added by paragraph (2)(A)), both overall and among providers specializing in mental health or substance use disorder treatment;

(iii) - provider response rates by plan verification methods;

(iv) - administrative costs to providers and Medicare Advantage organizations; and

(v) - other items determined appropriate by the Comptroller General.

(B) Report - Not later than January 15, 2032, the Comptroller General shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.

(1) Stakeholder meeting -

(A) In general - Not later than 3 months after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this subsection as the Secretary) shall hold a public meeting to receive input on approaches for maintaining accurate provider directories for Medicare Advantage plans under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w–21 et seq.), including input on approaches for reducing administrative burden, such as data standardization, and best practices to maintain accurate provider directory information.

(B) Participants - Participants of the meeting under subparagraph (A) shall include representatives from the Centers for Medicare & Medicaid Services and the Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology. Such meeting shall be open to the public. To the extent practicable, the Secretary shall include health care providers, companies that specialize in relevant technologies, health insurers, and patient advocates.

(2) Guidance to Medicare Advantage organizations - Not later than 12 months after the date of enactment of this Act, the Secretary shall issue guidance to Medicare Advantage organizations offering Medicare Advantage plans under part C of title XVIII of the Social Security Act (42 U.S.C. 1395w–21 et seq.) on maintaining accurate provider directories for such plans, taking into consideration input received during the stakeholder meeting under paragraph (1). Such guidance may include the following, as determined appropriate by the Secretary:

(A) - Best practices for Medicare Advantage organizations on how to work with providers to maintain the accuracy of provider directories and reduce provider and Medicare Advantage organization burden with respect to maintaining the accuracy of provider directories.

(B) - Information on data sets and data sources with information that could be used by Medicare Advantage organizations to maintain accurate provider directories.

(C) - Approaches for utilizing data sources maintained by Medicare Advantage organizations and publicly available data sets to maintain accurate provider directories.

(D) - Information to be included in provider directories that may be useful for Medicare beneficiaries to assess plan networks when selecting a plan and accessing providers participating in plan networks during the plan year.

(3) Guidance to part B providers - Not later than 12 months after the date of enactment of this Act, the Secretary shall issue guidance to providers of services and suppliers who furnish items or services for which benefits are available under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) on when to update the National Plan and Provider Enumeration System for information changes.

119-HR5281

REAL Health Providers Act

119th CONGRESS

1st Session

H. R. 5281

1. Short title

2. Provider directory requirements under Medicare Advantage