Requiring enhanced & accurate lists of (real) health providers act

(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 before the period at the end: , and, in the case of a network-based 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 plan (as defined in subparagraph (C)) shall, for each network-based 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;(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 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)

Network-based plan

In this paragraph, the term network-based plan has the meaning given that term in subsection (d)(5)(C), except such term includes a Medicare Advantage private fee-for-service plan, as determined appropriate by the Secretary.

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

Determination of accuracy score

(i)

In general

The Secretary shall specify methodologies for MA plans to use in estimating the accuracy of the provider directory information of such plans and determining the accuracy score for the plan’s provider directory.(ii)

Considerations

In carrying out clause (i), the Secretary shall take into consideration—(I)data sources maintained by MA organizations;(II)publicly available data sets;(III)the administrative burden on plans and providers; and(IV)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 network-based plan with low enrollment (as defined by the Secretary).(D)

Transparency

Beginning with plan years beginning on or after January 1, 2027, 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.(E)

Implementation

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

(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, 2027, the accuracy score of the plan’s provider directory (as reported under section 1857(e)(6)(A)(ii)) 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, $1,000,000 for fiscal year 2025, 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 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 protections required under section 1852(d)(7) of the Social Security Act, as added by paragraph (1);(ii)the provider directory accuracy scores trends 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 disorder treatment;(iii)provider response rates by plan verification methods; and(iv)other items determined appropriate by the Comptroller General.(B)

Report

Not later than January 15, 2031, 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 stakeholder 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 provider directory information.(B)

Participants

Participants of the meeting under subparagraph (A) shall include representatives from the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology, 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 the provider directory 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 regarding any information changes.