Short title

This Act may be cited as the

Requiring Enhanced & Accurate Lists of Health Providers Act

or the

REAL Health Providers Act

Provider directory requirements

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 network-based MA plan (as defined in paragraph (3)(C)), for plan year 2026 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 2026 and subsequent plan years, each MA organization offering a network-based MA plan shall, for each network-based MA 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, verify in a manner specified by the Secretary 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;(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; and(v)meet such other requirements as the Secretary may specify.(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 plan has an agreement for furnishing items and services covered under such plan such as name, specialty, contact information, primary office or facility address, availability, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.(C)

Network-based MA plan defined

In this paragraph, the term network-based MA plan means an MA plan that has a network of providers that contract or make arrangements with the MA organization offering the plan to furnish items and services covered under such plan.

Accountability for provider directory accuracy

(a)

Cost Sharing for Services Furnished Based on Reliance on Incorrect Provider Network Information

Section 1852(d) of the Social Security Act (42 U.S.C. 1395w–22(d)) is amended by adding at the end the following new paragraph:

(7)

Cost sharing for services furnished based on reliance on incorrect provider network information

(A)

In general

For plan year 2026 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 network-based 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, the MA organization offering such plan shall ensure that the enrollee is only responsible for the amount of cost sharing that would apply if such provider had been participating in the network of such plan.(B)

Notification requirement

For plan year 2026 and subsequent plan years, each MA organization that offers a network-based 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 network-based MA plan offered by the MA organization; and(iii)notify enrollees of their cost-sharing protections under this paragraph in an explanation of benefits.

(b)

Required provider directory accuracy analysis and reports

(1)

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, 2026, subject to subparagraph (C), a contract under this section with an MA organization shall require the organization, for each network-based MA plan (as defined in section 1852(c)(3)(C)) offered by the organization, to annually—(i)conduct an analysis of the accuracy of the provider directory of such plan (including provider types with high inaccuracy rates, such as providers specializing in mental health and substance use disorder treatment, as determined by the Secretary); and (ii)submit a report to the Secretary containing the results of such analysis and other information required by the Secretary.(B)

Considerations

In establishing requirements with respect to analysis and reporting under this paragraph, the Secretary shall take into account—(i) data sources maintained by of MA organizations; (ii)publicly available data sets; and(iii)the administrative burden of maintaining provider directories on plans and providers.(C)

Exception

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

Transparency

The Secretary shall post accuracy scores (as reported under subparagraph (A)), in a machine readable file, on the internet website of the Centers for Medicare & Medicaid Services. (E)

Implementation

The Secretary shall implement this paragraph through notice and comment rulemaking.

(2)

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

Information regarding the accuracy of the plan’s provider directory (as reported under section 1857(e)(6)) on the plan’s provider directory.

(3)

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, $1,000,000 for fiscal year 2026, to remain available until expended, to carry out the amendments made by this subsection.(c)

GAO study and report

(1)

Analysis

The Comptroller General of the United States (in this subsection referred to as the Comptroller General) shall conduct study of the implementation of the amendments made by subsections (a) and (b). Such study shall include an analysis of—(A)the use of protections required under section 1852(d)(7) of the Social Security Act, as added by subsection (a);(B)the provider directory accuracy scores trends under section 1857(e)(6) of the Social Security Act (as added by subsection (b)(1)), both overall and among providers specializing in mental health and substance disorder treatment; and(C)other items determined appropriate by the Comptroller General.(2)

Report

Not later than January 1, 2031, the Comptroller General shall submit to Congress, the Commissioner of Social Security, and the Secretary of Health and Human Services a report containing the results of the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.

Guidance on best practices for maintaining accurate provider directories

Not later than 12 months after the date of enactment of this Act, the Secretary of Health and Human Services 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. Such guidance may include the following, as determined appropriate by the Secretary:(1)Best practices for Medicare Advantage plans on how to work with providers to maintain the accuracy of provider directories of such plans and reduce provider and Medicare Advantage plan burden.(2)Information on data sets and data sources with information that could be used by such plans to maintain accurate provider directories.(3)Approaches for utilizing existing information assets of plans and publicly available data sets and data sources to maintain accurate provider directories.(4)Information that may be useful for beneficiaries to assess plan networks when selecting a plan and accessing providers participating in plan networks during the plan year.