HR5281-119

What This Bill Does

The REAL Health Providers Act creates Medicare Advantage provider-directory accuracy duties. Starting with plan year 2028, network-based MA plans and certain private fee-for-service MA plans must maintain accurate public provider directories with provider name, specialty, contact information, office or facility address, new-patient status, disability accommodations, cultural and linguistic capabilities, and telehealth capabilities. Plans must verify provider information at least every 90 days, with hospital or facility verification no less often than annually, flag unverified information, and remove nonparticipating providers within five business days. If an enrollee makes an appointment with a provider listed in the directory who is not actually in-network, the MA organization must limit cost sharing to the lesser of in-network cost sharing or otherwise applicable cost sharing. Plans must notify enrollees of these protections and include them in directories and explanations of benefits. From plan years beginning in 2028, MA contracts must require annual random-sample accuracy analyses, with attention to high-inaccuracy specialties such as mental health or substance use disorder treatment. CMS must specify verification methods, publish plan accuracy scores in machine-readable form from 2029, and require scores to appear prominently in plan directories. The bill appropriates $4 million for CMS Program Management for fiscal 2026, requires GAO to study implementation by January 15, 2032, and requires HHS public meetings and guidance for MA plans and providers.

Who Benefits and How

Medicare Advantage enrollees benefit because provider directories must be accurate, updated, and paired with cost-sharing protection when listed providers are out of network. Patients seeking mental health care benefit because accuracy sampling must focus on specialties with high directory inaccuracy, including mental health or substance use disorder providers. CMS oversight staff benefit from plan-level accuracy scores, machine-readable public posting, and new verification methods. Patient advocacy organizations benefit from public meetings, directory accuracy guidance, and stronger consumer information.

Who Bears the Burden and How

Medicare Advantage organizations must verify directories every 90 days, flag unverified providers, remove nonparticipating providers within five business days, and report annual accuracy scores. Health care providers must respond to directory verification requests and update National Plan and Provider Enumeration System information. CMS Program Management staff must issue methods, guidance, public postings, and implementation rules using the $4 million appropriation. GAO analysts must study cost-sharing protections, accuracy scores, provider response rates, administrative costs, and implementation by 2032.

Key Provisions

• Requires specified Medicare Advantage plans to maintain accurate public provider directories beginning in plan year 2028.
• Requires 90-day verification for most providers and at least annual verification for hospitals or facilities.
• Protects enrollees from higher cost sharing when directories list providers that are not actually in network.
• Requires annual directory accuracy analyses and CMS publication of accuracy scores beginning in 2029.
• Appropriates $4 million for CMS implementation and requires GAO study plus HHS stakeholder guidance.