[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 7708 Introduced in House (IH)]
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118th CONGRESS
2d Session
H. R. 7708
To amend title XVIII of the Social Security Act to require MA
organizations offering network-based plans to maintain an accurate
provider directory, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 15, 2024
Mr. Panetta (for himself, Mr. Murphy, Ms. Kuster, 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 require MA
organizations offering network-based plans to maintain an accurate
provider directory, 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. 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.
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