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