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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5281 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 5281
To amend title XVIII of the Social Security Act to establish provider
directory requirements, and to provide accountability for provider
directory accuracy, under Medicare Advantage.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 10, 2025
Mr. Panetta (for himself, Mr. Murphy, Mr. Landsman, Mr. Schneider, and
Mr. Fitzpatrick) introduced the following bill; which was 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
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to establish provider
directory requirements, and to provide accountability for provider
directory accuracy, under Medicare Advantage.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 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''.
SEC. 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) 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.
``(C) Specified ma plan.--In this paragraph, the
term `specified MA plan' means--
``(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);''; and
(B) 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.
(c) Guidance on Maintaining Accurate Provider Directories.--
(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.
<all>
Introduced in House
Introduced in House
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.
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.
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