[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 2793 Introduced in Senate (IS)]
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119th CONGRESS
1st Session
S. 2793
To amend title XVIII of the Social Security Act to require Medicare
Advantage plans to cover items and services furnished by certain
essential community providers within a service area, and for other
purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
September 11, 2025
Mr. Cassidy (for himself and Mr. Lujan) 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 require Medicare
Advantage plans to cover items and services furnished by certain
essential community providers within a service area, 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. SHORT TITLE.
This Act may be cited as the ``Ensuring Access to Essential
Providers Act of 2025''.
SEC. 2. MEDICARE ADVANTAGE ESSENTIAL COMMUNITY PROVIDERS.
Section 1852(d) of the Social Security Act (42 U.S.C. 1395w-22(d))
is amended--
(1) in paragraph (1)--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(F) the organization meets the essential
community provider standard, as described in paragraph
(7).''; and
(2) by adding at the end the following new paragraph:
``(7) Essential community provider standard.--
``(A) In general.--For purposes of paragraph (1)(F)
and subject to subparagraph (B), in order to meet the
essential community provider standard, an MA
organization shall--
``(i) include an amount (determined by the
Secretary) of available essential community
providers (as described in subparagraph (E)) in
each MA plan's service area in the provider
network and offer to contract with each
essential community provider in the service
area of each plan;
``(ii) include in its provider network a
sufficient number and a geographic
distribution, as determined by the Secretary,
of available essential community providers,
where available, to ensure low-income
individuals, individuals residing in rural
areas, or individuals residing in areas
designated as health professional shortage
areas under section 332(a)(1)(A) of the Public
Health Service Act within the service area of
the MA organization have reasonable and timely
access to a broad range of such providers; and
``(iii) meet the payment requirements to
Federally qualified health centers, as
described in subparagraph (C).
``(B) Justification for not meeting standard.--
``(i) In general.--If an MA plan does not
meet the essential community provider standard
described in subparagraph (A), the MA
organization offering such plan shall include
as part of the information required to be
submitted under section 1854(a)--
``(I) an explanation regarding why
the plan was unable to meet such
standard; and
``(II) a narrative justification
describing how the provider network of
such plan--
``(aa) provides an adequate
level of service for low-income
enrollees or individuals
residing in areas designated as
health professional shortage
areas within the service area
of such plan; and
``(bb) will move toward
satisfaction of the essential
community provider standard
prior to the start of the next
plan year.
``(ii) Insufficient justification.--If the
Secretary determines that the MA organization
does not sufficiently explain why the
applicable MA plan does not meet the essential
community provider standard in the information
described in clause (i), the Secretary shall
not approve such plan.
``(C) Payment to federally qualified health
centers.--An MA organization shall pay a Federally
qualified health center for an item or service an
amount consistent with section 1857(e)(3).
``(D) Clarification.--Nothing in this paragraph may
be construed to require an MA plan to provide coverage
for a specific medical procedure.
``(E) Essential community provider.--For purposes
of this paragraph, the term `essential community
provider' means a provider that serves predominantly
low-income, medically underserved individuals,
including--
``(i) a Federally qualified health center
and any similar clinic;
``(ii) a facility funded by the program
under title XXVI of the Public Health Service
Act (42 U.S.C. 300ff-11 et seq.; commonly
referred to as the `Ryan White HIV/AIDS
Program');
``(iii) a facility operated by the Indian
Health Service, an Indian tribe or tribal
organization, or an urban Indian organization
(as defined in section 4 of the Indian Health
Care Improvement Act);
``(iv) a hospital, including an inpatient
hospital, a hospital receiving or eligible to
receive disproportionate share hospital
payments under section 1886(d)(5)(F), a
hospital classified as a rural referral center
under section 1886(d)(5)(C), a sole community
hospital (as defined in section
1886(d)(5)(D)(iii)), a free-standing cancer
hospital (as described in section
1886(d)(1)(B)(v)), and a critical access
hospital (as defined in section 1861(mm)(1));
``(v) a mental health or substance use
treatment facility;
``(vi) any other entity that serves
predominantly low-income, medically underserved
individuals, including--
``(I) an entity receiving funds
under section 318 of the Public Health
Service Act (relating to treatment of
sexually transmitted diseases) through
a State or unit of local government,
but only if the entity is certified by
the Secretary pursuant to section
340B(a)(7) of such Act;
``(II) a tuberculosis clinic;
``(III) a comprehensive hemophilia
diagnostic treatment center receiving a
grant under section 501(a)(2); and
``(IV) a black lung clinic
receiving funds under section 427(a) of
the Black Lung Benefits Act;
``(vii) a medicare-dependent, small rural
hospital (as defined in section
1886(d)(4)(G)(iv)); and
``(viii) any provider determined
appropriate by the Secretary, which may include
any provider determined by the Secretary to be
an essential community provider under section
1311(c)(1)(C) of the Patient Protection and
Affordable Care Act (42 U.S.C.
18031(c)(1)(C)).''.
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