I
118THCONGRESS
2
DSESSION 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
MARCH15, 2024
Mr. P
ANETTA(for himself, Mr. MURPHY, Ms. KUSTER, Mr. SCHNEIDER, and
Mr. F
ITZPATRICK) introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on En-
ergy 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 main-
tain an accurate provider directory, and for other pur-
poses.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. REQUIRING ENHANCED & ACCURATE LISTS OF 3
(REAL) HEALTH PROVIDERS ACT. 4
(a) I
NGENERAL.—Section 1852(c) of the Social Se-5
curity Act (42 U.S.C. 1395w–22(c)) is amended— 6
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(1) in paragraph (1)(C)— 1
(A) by striking ‘‘plan, and any’’ and insert-2
ing ‘‘plan, any’’; and 3
(B) by inserting before the period at the 4
end: ‘‘, and, in the case of a network-based plan 5
(as defined in paragraph (3)(C)), for plan year 6
2026 and subsequent plan years, the informa-7
tion described in paragraph (3)(B)’’; and 8
(2) by adding at the end the following new 9
paragraph: 10
‘‘(3) P
ROVIDER DIRECTORY ACCURACY .— 11
‘‘(A) I
N GENERAL.—For plan year 2026 12
and subsequent plan years, each MA organiza-13
tion offering a network-based plan (as defined 14
in subparagraph (C)) shall, for each network- 15
based plan offered by the organization— 16
‘‘(i) maintain, on a publicly available 17
internet website, an accurate provider di-18
rectory that includes the information de-19
scribed in subparagraph (B); 20
‘‘(ii) not less frequently than once 21
every 90 days (or, in the case of a hospital 22
or any other facility determined appro-23
priate by the Secretary, at a lesser fre-24
quency specified by the Secretary but in no 25
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case less frequently than once every 12 1
months), verify the provider directory in-2
formation of each provider listed in such 3
directory and, if applicable, update such 4
provider directory information; 5
‘‘(iii) if the organization is unable to 6
verify such information with respect to a 7
provider, include in such directory an indi-8
cation that the information of such pro-9
vider may not be up to date; 10
‘‘(iv) remove a provider from such di-11
rectory within 5 business days if the orga-12
nization determines that the provider is no 13
longer a provider participating in the net-14
work of such plan; and 15
‘‘(v) meet such other requirements as 16
the Secretary may specify. 17
‘‘(B) P
ROVIDER DIRECTORY INFORMA -18
TION.—The information described in this sub-19
paragraph is information enrollees may need to 20
access covered benefits from a provider with 21
which such organization offering such plan has 22
an agreement for furnishing items and services 23
covered under such plan such as name, spe-24
cialty, contact information, primary office or fa-25
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cility address, whether the provider is accepting 1
new patients, accommodations for people with 2
disabilities, cultural and linguistic capabilities, 3
and telehealth capabilities. 4
‘‘(C) N
ETWORK-BASED PLAN.—In this 5
paragraph, the term ‘network-based plan’ has 6
the meaning given that term in subsection 7
(d)(5)(C), except such term includes a Medicare 8
Advantage private fee-for-service plan, as deter-9
mined appropriate by the Secretary.’’. 10
(b) A
CCOUNTABILITY FOR PROVIDERDIRECTORY 11
A
CCURACY.— 12
(1) C
OST SHARING FOR SERVICES FURNISHED 13
BASED ON RELIANCE ON INCORRECT PROVIDER DI -14
RECTORY INFORMATION .—Section 1852(d) of the 15
Social Security Act (42 U.S.C. 1395w–22(d)) is 16
amended— 17
(A) in paragraph (1)(C)— 18
(i) in clause (ii), by striking ‘‘or’’ at 19
the end; 20
(ii) in clause (iii), by striking the 21
semicolon at the end and inserting ‘‘, or’’; 22
and 23
(iii) by adding at the end the fol-24
lowing new clause: 25
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‘‘(iv) the services are furnished by a 1
provider that is not participating in the 2
network of a network-based plan (as de-3
fined in subsection (c)(3)(C)) but is listed 4
in the provider directory of such plan on 5
the date on which the appointment is 6
made, as described in paragraph (7)(A);’’; 7
and 8
(B) by adding at the end the following new 9
paragraph: 10
‘‘(7) C
OST SHARING FOR SERVICES FURNISHED 11
BASED ON RELIANCE ON INCORRECT PROVIDER DI -12
RECTORY INFORMATION .— 13
‘‘(A) I
N GENERAL.—For plan year 2026 14
and subsequent plan years, if an enrollee is fur-15
nished an item or service by a provider that is 16
not participating in the network of a network- 17
based plan (as defined in subsection (c)(3)(C)) 18
but is listed in the provider directory of such 19
plan (as required to be provided to an enrollee 20
pursuant to subsection (c)(1)(C)) on the date 21
on which the appointment is made, and if such 22
item or service would otherwise be covered 23
under such plan if furnished by a provider that 24
is participating in the network of such plan, the 25
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MA organization offering such plan shall ensure 1
that the enrollee is only responsible for the 2
amount of cost sharing that would apply if such 3
provider had been participating in the network 4
of such plan. 5
‘‘(B) N
OTIFICATION REQUIREMENT .—For 6
plan year 2026 and subsequent plan years, each 7
MA organization that offers a network-based 8
plan shall— 9
‘‘(i) notify enrollees of their cost-shar-10
ing protections under this paragraph and 11
make such notifications, to the extent 12
practicable, by not later than the first day 13
of an annual, coordinated election period 14
under section 1851(e)(3) with respect to a 15
year; 16
‘‘(ii) include information regarding 17
such cost-sharing protections in the pro-18
vider directory of each network-based plan 19
offered by the MA organization.; and 20
‘‘(iii) notify enrollees of their cost- 21
sharing protections under this paragraph 22
in an explanation of benefits.’’. 23
(2) R
EQUIRED PROVIDER DIRECTORY ACCU -24
RACY ANALYSIS AND REPORTS .— 25
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(A) IN GENERAL.—Section 1857(e) of the 1
Social Security Act (42 U.S.C. 1395w–27(e)) is 2
amended by adding at the end the following 3
new paragraph: 4
‘‘(6) P
ROVIDER DIRECTORY ACCURACY ANAL -5
YSIS AND REPORTS.— 6
‘‘(A) I
N GENERAL.—Beginning with plan 7
years beginning on or after January 1, 2026, 8
subject to subparagraph (C), a contract under 9
this section with an MA organization shall re-10
quire the organization, for each network-based 11
plan (as defined in section 1852(c)(3)(C)) of-12
fered by the organization, to annually— 13
‘‘(i) conduct an analysis estimating 14
the accuracy of the provider directory of 15
such plan using a sample of providers in-16
cluded in such provider directory (includ-17
ing provider specialties with high inaccu-18
racy rates of provider directory informa-19
tion, such as providers specializing in men-20
tal health or substance use disorder treat-21
ment, as determined by the Secretary); and 22
‘‘(ii) submit a report to the Secretary 23
containing the results of such analysis, in-24
cluding an accuracy score for such provider 25
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directory (as determined using a method-1
ology specified by the Secretary under sub-2
paragraph (B)(i)), and other information 3
required by the Secretary. 4
‘‘(B) D
ETERMINATION OF ACCURACY 5
SCORE.— 6
‘‘(i) I
N GENERAL.—The Secretary 7
shall specify methodologies for MA plans 8
to use in estimating the accuracy of the 9
provider directory information of such 10
plans and determining the accuracy score 11
for the plan’s provider directory. 12
‘‘(ii) C
ONSIDERATIONS.—In carrying 13
out clause (i), the Secretary shall take into 14
consideration— 15
‘‘(I) data sources maintained by 16
MA organizations; 17
‘‘(II) publicly available data sets; 18
‘‘(III) the administrative burden 19
on plans and providers; and 20
‘‘(IV) the relative importance of 21
certain provider directory information 22
on enrollee ability to access care. 23
‘‘(C) E
XCEPTION.—The Secretary may 24
waive the requirements of this paragraph in the 25
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case of a network-based plan with low enroll-1
ment (as defined by the Secretary). 2
‘‘(D) T
RANSPARENCY.—Beginning with 3
plan years beginning on or after January 1, 4
2027, the Secretary shall post accuracy scores 5
(as reported under subparagraph (A)(ii)), in a 6
machine readable file, on the internet website of 7
the Centers for Medicare & Medicaid Services. 8
‘‘(E) I
MPLEMENTATION.—The Secretary 9
shall implement this paragraph through notice 10
and comment rulemaking.’’. 11
(B) P
ROVISION OF INFORMATION TO 12
BENEFICIARIES.—Section 1851(d)(4) of the So-13
cial Security Act (42 U.S.C. 1395w–21(d)(4)) 14
is amended by adding at the end the following 15
new subparagraph: 16
‘‘(F) P
ROVIDER DIRECTORY .—Beginning 17
with plan years beginning on or after January 18
1, 2027, the accuracy score of the plan’s pro-19
vider directory (as reported under section 20
1857(e)(6)(A)(ii)) on the plan’s provider direc-21
tory.’’. 22
(C) F
UNDING.—In addition to amounts 23
otherwise available, there is appropriated to the 24
Centers for Medicare & Medicaid Services Pro-25
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gram Management Account, out of any money 1
in the Treasury not otherwise appropriated, 2
$1,000,000 for fiscal year 2025, to remain 3
available until expended, to carry out the 4
amendments made by this paragraph. 5
(3) GAO
STUDY AND REPORT.— 6
(A) A
NALYSIS.—The Comptroller General 7
of the United States (in this paragraph referred 8
to as the ‘‘Comptroller General’’) shall conduct 9
study of the implementation of the amendments 10
made by paragraphs (1) and (2). To the extent 11
data are available and reliable, such study shall 12
include an analysis of— 13
(i) the use of protections required 14
under section 1852(d)(7) of the Social Se-15
curity Act, as added by paragraph (1); 16
(ii) the provider directory accuracy 17
scores trends under section 18
1857(e)(6)(A)(ii) of the Social Security 19
Act (as added by paragraph (2)(A)), both 20
overall and among providers specializing in 21
mental health or substance disorder treat-22
ment; 23
(iii) provider response rates by plan 24
verification methods; and 25
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(iv) other items determined appro-1
priate by the Comptroller General. 2
(B) R
EPORT.—Not later than January 15, 3
2031, the Comptroller General shall submit to 4
Congress a report containing the results of the 5
study conducted under subparagraph (A), to-6
gether with recommendations for such legisla-7
tion and administrative action as the Comp-8
troller General determines appropriate. 9
(c) G
UIDANCE ON MAINTAININGACCURATEPRO-10
VIDERDIRECTORIES.— 11
(1) S
TAKEHOLDER MEETING .— 12
(A) I
N GENERAL.—Not later than 3 13
months after the date of enactment of this Act, 14
the Secretary of Health and Human Services 15
(referred to in this subsection as the ‘‘Sec-16
retary’’) shall hold a public stakeholder meeting 17
to receive input on approaches for maintaining 18
accurate provider directories for Medicare Ad-19
vantage plans under part C of title XVIII of the 20
Social Security Act (42 U.S.C. 1395w–21 et 21
seq.), including input on approaches for reduc-22
ing administrative burden such as data stand-23
ardization and best practices to maintain pro-24
vider directory information. 25
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(B) PARTICIPANTS.—Participants of the 1
meeting under subparagraph (A) shall include 2
representatives from the Centers for Medicare & 3
Medicaid Services and the Office of the Na-4
tional Coordinator for Health Information 5
Technology, health care providers, companies 6
that specialize in relevant technologies, health 7
insurers, and patient advocates. 8
(2) G
UIDANCE TO MEDICARE ADVANTAGE OR -9
GANIZATIONS.—Not later than 12 months after the 10
date of enactment of this Act, the Secretary shall 11
issue guidance to Medicare Advantage organizations 12
offering Medicare Advantage plans under part C of 13
title XVIII of the Social Security Act (42 U.S.C. 14
1395w–21 et seq.) on maintaining accurate provider 15
directories for such plans, taking into consideration 16
input received during the stakeholder meeting under 17
paragraph (1). Such guidance may include the fol-18
lowing, as determined appropriate by the Secretary: 19
(A) Best practices for Medicare Advantage 20
organizations on how to work with providers to 21
maintain the accuracy of provider directories 22
and reduce provider and Medicare Advantage 23
organization burden with respect to maintaining 24
the accuracy of provider directories. 25
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(B) Information on data sets and data 1
sources with information that could be used by 2
Medicare Advantage organizations to maintain 3
accurate provider directories. 4
(C) Approaches for utilizing data sources 5
maintained by Medicare Advantage organiza-6
tions and publicly available data sets to main-7
tain accurate provider directories. 8
(D) Information to be included in the pro-9
vider directory that may be useful for Medicare 10
beneficiaries to assess plan networks when se-11
lecting a plan and accessing providers partici-12
pating in plan networks during the plan year. 13
(3) G
UIDANCE TO PART B PROVIDERS .—Not 14
later than 12 months after the date of enactment of 15
this Act, the Secretary shall issue guidance to pro-16
viders of services and suppliers who furnish items or 17
services for which benefits are available under part 18
B of title XVIII of the Social Security Act (42 19
U.S.C. 1395j et seq.) on when to update the Na-20
tional Plan and Provider Enumeration System re-21
garding any information changes. 22
Æ
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