119-s2793

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 2793 Introduced in Senate

    (IS) ]

<DOC>

119th CONGRESS
 1st Session
 S. 2793

 To amend title XVIII of the Social Security Act to require Medicare 
 Advantage plans to cover items and services furnished by certain 
 essential community providers within a service area, and for other 
 purposes.

_______________________________________________________________________

 IN THE SENATE OF THE UNITED STATES

 September 11, 2025

Mr. Cassidy (for himself and Mr. Lujan) introduced the following bill; 
 which was read twice and referred to the Committee on Finance

_______________________________________________________________________

 A BILL

 To amend title XVIII of the Social Security Act to require Medicare 
 Advantage plans to cover items and services furnished by certain 
 essential community providers within a service area, and for other 
 purposes.

 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 ``Ensuring Access to Essential 
Providers Act of 2025''.

SEC. 2. MEDICARE ADVANTAGE ESSENTIAL COMMUNITY PROVIDERS.

 

Section 1852
            (d) of the Social Security Act (42 U.S.C. 1395w-22
            (d) ) 
is amended--

    (1) in paragraph

    (1) --
        (A) in subparagraph
            (D) , by striking ``and'' at the 
 end;
        (B) in subparagraph
        (E) , by striking the period at 
 the end and inserting ``; and''; and
            (C) by adding at the end the following new 
 subparagraph:
 ``
        (F) the organization meets the essential 
 community provider standard, as described in paragraph

    (7) .''; and

    (2) by adding at the end the following new paragraph:
 ``

    (7) Essential community provider standard.--
 ``
        (A) In general.--For purposes of paragraph

    (1)
        (F) and subject to subparagraph
        (B) , in order to meet the 
 essential community provider standard, an MA 
 organization shall--
 ``
            (i) include an amount (determined by the 
 Secretary) of available essential community 
 providers (as described in subparagraph
        (E) ) in 
 each MA plan's service area in the provider 
 network and offer to contract with each 
 essential community provider in the service 
 area of each plan;
 ``
            (ii) include in its provider network a 
 sufficient number and a geographic 
 distribution, as determined by the Secretary, 
 of available essential community providers, 
 where available, to ensure low-income 
 individuals, individuals residing in rural 
 areas, or individuals residing in areas 
 designated as health professional shortage 
 areas under 

section 332

    (a)

    (1)
        (A) of the Public 
 Health Service Act within the service area of 
 the MA organization have reasonable and timely 
 access to a broad range of such providers; and
 ``
            (iii) meet the payment requirements to 
 Federally qualified health centers, as 
 described in subparagraph
            (C) .
 ``
        (B) Justification for not meeting standard.--
 ``
            (i) In general.--If an MA plan does not 
 meet the essential community provider standard 
 described in subparagraph
        (A) , the MA 
 organization offering such plan shall include 
 as part of the information required to be 
 submitted under 

section 1854

    (a) --
 ``
            (I) an explanation regarding why 
 the plan was unable to meet such 
 standard; and
 ``
            (II) a narrative justification 
 describing how the provider network of 
 such plan--
 ``

    (aa) provides an adequate 
 level of service for low-income 
 enrollees or individuals 
 residing in areas designated as 
 health professional shortage 
 areas within the service area 
 of such plan; and
 ``

    (bb) will move toward 
 satisfaction of the essential 
 community provider standard 
 prior to the start of the next 
 plan year.
 ``
            (ii) Insufficient justification.--If the 
 Secretary determines that the MA organization 
 does not sufficiently explain why the 
 applicable MA plan does not meet the essential 
 community provider standard in the information 
 described in clause
            (i) , the Secretary shall 
 not approve such plan.
 ``
            (C) Payment to federally qualified health 
 centers.--An MA organization shall pay a Federally 
 qualified health center for an item or service an 
 amount consistent with 

section 1857

    (e)

    (3) .
 ``
            (D) Clarification.--Nothing in this paragraph may 
 be construed to require an MA plan to provide coverage 
 for a specific medical procedure.
 ``
        (E) Essential community provider.--For purposes 
 of this paragraph, the term `essential community 
 provider' means a provider that serves predominantly 
 low-income, medically underserved individuals, 
 including--
 ``
            (i) a Federally qualified health center 
 and any similar clinic;
 ``
            (ii) a facility funded by the program 
 under title XXVI of the Public Health Service 
 Act (42 U.S.C. 300ff-11 et seq.; commonly 
 referred to as the `Ryan White HIV/AIDS 
 Program');
 ``
            (iii) a facility operated by the Indian 
 Health Service, an Indian tribe or tribal 
 organization, or an urban Indian organization 
 (as defined in 

section 4 of the Indian Health 
 Care Improvement Act);
 ``
            (iv) a hospital, including an inpatient 
 hospital, a hospital receiving or eligible to 
 receive disproportionate share hospital 
 payments under 

section 1886
            (d) (5)
        (F) , a 
 hospital classified as a rural referral center 
 under 

section 1886
            (d) (5)
            (C) , a sole community 
 hospital (as defined in 

section 1886
            (d) (5)
            (D) 
            (iii) ), a free-standing cancer 
 hospital (as described in 

section 1886
            (d) (1)
        (B)
            (v) ), and a critical access 
 hospital (as defined in 

section 1861
            (mm) (1) );
 ``
            (v) a mental health or substance use 
 treatment facility;
 ``
            (vi) any other entity that serves 
 predominantly low-income, medically underserved 
 individuals, including--
 ``
            (I) an entity receiving funds 
 under 

section 318 of the Public Health 
 Service Act (relating to treatment of 
 sexually transmitted diseases) through 
 a State or unit of local government, 
 but only if the entity is certified by 
 the Secretary pursuant to 

section 340B

    (a)

    (7) of such Act;
 ``
            (II) a tuberculosis clinic;
 ``
            (III) a comprehensive hemophilia 
 diagnostic treatment center receiving a 
 grant under 

section 501

    (a)

    (2) ; and
 ``
            (IV) a black lung clinic 
 receiving funds under 

section 427

    (a) of 
 the Black Lung Benefits Act;
 ``
            (vii) a medicare-dependent, small rural 
 hospital (as defined in 

section 1886
            (d) (4)
        (G)
            (iv) ); and
 ``
            (viii) any provider determined 
 appropriate by the Secretary, which may include 
 any provider determined by the Secretary to be 
 an essential community provider under 

section 1311
            (c) (1)
            (C) of the Patient Protection and 
 Affordable Care Act (42 U.S.C. 
 18031
            (c) (1)
            (C) ).''.
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