119-hr5281

[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.
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