II
118THCONGRESS
1
STSESSION S. 3059
To amend title XVIII of the Social Security Act to establish provider directory
requirements, and to provide accountability for provider directory accu-
racy, under Medicare Advantage.
IN THE SENATE OF THE UNITED STATES
OCTOBER17, 2023
Mr. B
ENNET(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 account-
ability for provider directory accuracy, under Medicare
Advantage.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Requiring Enhanced 4
& Accurate Lists of Health Providers Act’’ or the ‘‘REAL 5
Health Providers Act’’. 6
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•S 3059 IS
SEC. 2. PROVIDER DIRECTORY REQUIREMENTS. 1
Section 1852(c) of the Social Security Act (42 U.S.C. 2
1395w–22(c)) is amended— 3
(1) in paragraph (1)(C)— 4
(A) by striking ‘‘plan, and any’’ and insert-5
ing ‘‘plan, any’’; and 6
(B) by inserting the following before the 7
period: ‘‘, and, in the case of a network-based 8
MA plan (as defined in paragraph (3)(C)), for 9
plan year 2026 and subsequent plan years, the 10
information described in paragraph (3)(B)’’; 11
and 12
(2) by adding at the end the following new 13
paragraph: 14
‘‘(3) P
ROVIDER DIRECTORY ACCURACY .— 15
‘‘(A) I
N GENERAL.—For plan year 2026 16
and subsequent plan years, each MA organiza-17
tion offering a network-based MA plan shall, 18
for each network-based MA plan offered by the 19
organization— 20
‘‘(i) maintain, on a publicly available 21
internet website, an accurate provider di-22
rectory that includes the information de-23
scribed in subparagraph (B); 24
‘‘(ii) not less frequently than once 25
every 90 days, verify in a manner specified 26
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•S 3059 IS
by the Secretary the provider directory in-1
formation of each provider listed in such 2
directory and, if applicable, update such 3
provider directory information; 4
‘‘(iii) if the organization is unable to 5
verify such information with respect to a 6
provider, include in such directory an indi-7
cation that the information of such pro-8
vider may not be up to date; 9
‘‘(iv) remove a provider from such di-10
rectory within 5 business days if the orga-11
nization determines that the provider is no 12
longer a provider participating in the net-13
work of such plan; and 14
‘‘(v) meet such other requirements as 15
the Secretary may specify. 16
‘‘(B) P
ROVIDER DIRECTORY INFORMA -17
TION.—The information described in this sub-18
paragraph is information enrollees may need to 19
access covered benefits from a provider with 20
which such plan has an agreement for fur-21
nishing items and services covered under such 22
plan such as name, specialty, contact informa-23
tion, primary office or facility address, avail-24
ability, accommodations for people with disabil-25
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•S 3059 IS
ities, cultural and linguistic capabilities, and 1
telehealth capabilities. 2
‘‘(C) N
ETWORK-BASED MA PLAN DE -3
FINED.—In this paragraph, the term ‘network- 4
based MA plan’ means an MA plan that has a 5
network of providers that contract or make ar-6
rangements with the MA organization offering 7
the plan to furnish items and services covered 8
under such plan.’’. 9
SEC. 3. ACCOUNTABILITY FOR PROVIDER DIRECTORY AC-10
CURACY. 11
(a) C
OSTSHARING FOR SERVICESFURNISHED 12
B
ASED ONRELIANCE ONINCORRECTPROVIDERNET-13
WORKINFORMATION.—Section 1852(d) of the Social Se-14
curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 15
at the end the following new paragraph: 16
‘‘(7) C
OST SHARING FOR SERVICES FURNISHED 17
BASED ON RELIANCE ON INCORRECT PROVIDER NET -18
WORK INFORMATION .— 19
‘‘(A) I
N GENERAL.—For plan year 2026 20
and subsequent plan years, if an enrollee is fur-21
nished an item or service by a provider that is 22
not participating in the network of a network- 23
based MA plan (as defined in subsection 24
(c)(3)(C)) but is listed in the provider directory 25
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of such plan (as required to be provided to an 1
enrollee pursuant to subsection (c)(1)(C)) on 2
the date on which the appointment is made, the 3
MA organization offering such plan shall ensure 4
that the enrollee is only responsible for the 5
amount of cost sharing that would apply if such 6
provider had been participating in the network 7
of such plan. 8
‘‘(B) N
OTIFICATION REQUIREMENT .—For 9
plan year 2026 and subsequent plan years, each 10
MA organization that offers a network-based 11
MA plan shall— 12
‘‘(i) notify enrollees of their cost-shar-13
ing protections under this paragraph and 14
make such notifications, to the extent 15
practicable, by not later than the first day 16
of an annual, coordinated election period 17
under section 1851(e)(3) with respect to a 18
year; 19
‘‘(ii) include information regarding 20
such cost-sharing protections in the pro-21
vider directory of each network-based MA 22
plan offered by the MA organization; and 23
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‘‘(iii) notify enrollees of their cost- 1
sharing protections under this paragraph 2
in an explanation of benefits.’’. 3
(b) R
EQUIREDPROVIDERDIRECTORYACCURACY 4
A
NALYSIS ANDREPORTS.— 5
(1) I
N GENERAL.—Section 1857(e) of the So-6
cial Security Act (42 U.S.C. 1395w–27(e)) is 7
amended by adding at the end the following new 8
paragraph: 9
‘‘(6) P
ROVIDER DIRECTORY ACCURACY ANAL -10
YSIS AND REPORTS.— 11
‘‘(A) I
N GENERAL.—Beginning with plan 12
years beginning on or after January 1, 2026, 13
subject to subparagraph (C), a contract under 14
this section with an MA organization shall re-15
quire the organization, for each network-based 16
MA plan (as defined in section 1852(c)(3)(C)) 17
offered by the organization, to annually— 18
‘‘(i) conduct an analysis of the accu-19
racy of the provider directory of such plan 20
(including provider types with high inaccu-21
racy rates, such as providers specializing in 22
mental health and substance use disorder 23
treatment, as determined by the Sec-24
retary); and 25
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‘‘(ii) submit a report to the Secretary 1
containing the results of such analysis and 2
other information required by the Sec-3
retary. 4
‘‘(B) C
ONSIDERATIONS.—In establishing 5
requirements with respect to analysis and re-6
porting under this paragraph, the Secretary 7
shall take into account— 8
‘‘(i) data sources maintained by of 9
MA organizations; 10
‘‘(ii) publicly available data sets; and 11
‘‘(iii) the administrative burden of 12
maintaining provider directories on plans 13
and providers. 14
‘‘(C) E
XCEPTION.—The Secretary may 15
waive the requirements of this paragraph in the 16
case of a network-based MA plan with low en-17
rollment (as defined by the Secretary). 18
‘‘(D) T
RANSPARENCY.—The Secretary 19
shall post accuracy scores (as reported under 20
subparagraph (A)), in a machine readable file, 21
on the internet website of the Centers for Medi-22
care & Medicaid Services. 23
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‘‘(E) IMPLEMENTATION.—The Secretary 1
shall implement this paragraph through notice 2
and comment rulemaking.’’. 3
(2) P
ROVISION OF INFORMATION TO BENE -4
FICIARIES.—Section 1851(d)(4) of the Social Secu-5
rity Act (42 U.S.C. 1395w–21(d)(4)) is amended by 6
adding at the end the following new subparagraph: 7
‘‘(F) P
ROVIDER DIRECTORY.—Information 8
regarding the accuracy of the plan’s provider 9
directory (as reported under section 1857(e)(6)) 10
on the plan’s provider directory.’’. 11
(3) F
UNDING.—In addition to amounts other-12
wise available, there is appropriated to the Centers 13
for Medicare & Medicaid Services Program Manage-14
ment Account, out of any money in the Treasury not 15
otherwise appropriated, $1,000,000 for fiscal year 16
2026, to remain available until expended, to carry 17
out the amendments made by this subsection. 18
(c) GAO S
TUDY ANDREPORT.— 19
(1) A
NALYSIS.—The Comptroller General of the 20
United States (in this subsection referred to as the 21
‘‘Comptroller General’’) shall conduct study of the 22
implementation of the amendments made by sub-23
sections (a) and (b). Such study shall include an 24
analysis of— 25
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(A) the use of protections required under 1
section 1852(d)(7) of the Social Security Act, 2
as added by subsection (a); 3
(B) the provider directory accuracy scores 4
trends under section 1857(e)(6) of the Social 5
Security Act (as added by subsection (b)(1)), 6
both overall and among providers specializing in 7
mental health and substance disorder treat-8
ment; and 9
(C) other items determined appropriate by 10
the Comptroller General. 11
(2) R
EPORT.—Not later than January 1, 2031, 12
the Comptroller General shall submit to Congress, 13
the Commissioner of Social Security, and the Sec-14
retary of Health and Human Services a report con-15
taining the results of the study conducted under 16
paragraph (1), together with recommendations for 17
such legislation and administrative action as the 18
Comptroller General determines appropriate. 19
SEC. 4. GUIDANCE ON BEST PRACTICES FOR MAINTAINING 20
ACCURATE PROVIDER DIRECTORIES. 21
Not later than 12 months after the date of enactment 22
of this Act, the Secretary of Health and Human Services 23
shall issue guidance to Medicare Advantage organizations 24
offering Medicare Advantage plans under part C of title 25
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XVIII of the Social Security Act (42 U.S.C. 1395w–21 1
et seq.) on maintaining accurate provider directories for 2
such plans. Such guidance may include the following, as 3
determined appropriate by the Secretary: 4
(1) Best practices for Medicare Advantage 5
plans on how to work with providers to maintain the 6
accuracy of provider directories of such plans and 7
reduce provider and Medicare Advantage plan bur-8
den. 9
(2) Information on data sets and data sources 10
with information that could be used by such plans 11
to maintain accurate provider directories. 12
(3) Approaches for utilizing existing informa-13
tion assets of plans and publicly available data sets 14
and data sources to maintain accurate provider di-15
rectories. 16
(4) Information that may be useful for bene-17
ficiaries to assess plan networks when selecting a 18
plan and accessing providers participating in plan 19
networks during the plan year. 20
Æ
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