[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 3059 Introduced in Senate (IS)]

<DOC>






118th CONGRESS
  1st Session
                                S. 3059

 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 SENATE OF THE UNITED STATES

                            October 17, 2023

  Mr. Bennet (for himself, Mr. Tillis, and Mr. Wyden) 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 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 & Accurate Lists 
of Health Providers Act'' or the ``REAL Health Providers Act''.

SEC. 2. 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.''.

SEC. 3. 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.

SEC. 4. 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.
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