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.
Analysis under review: This bill has generated analysis that may be too generic or incomplete. Clause-level evidence remains available below.
Summary
What This Bill Does
This bill requires Medicare Advantage health insurance plans to include safety-net healthcare providers in their networks. These "essential community providers" include federally qualified health centers, rural hospitals, mental health facilities, and other providers that serve predominantly low-income and medically underserved communities. The goal is to ensure Medicare Advantage enrollees have access to these critical providers.
Who Benefits and How
Low-income Medicare beneficiaries, rural residents, and people in health professional shortage areas benefit by gaining guaranteed access to safety-net providers through their MA plans. Essential community providers (FQHCs, rural hospitals, mental health facilities, Ryan White clinics, Indian Health Service facilities) benefit from required inclusion in MA networks and guaranteed payment rates, increasing their patient base and revenue stability.
Who Bears the Burden and How
Medicare Advantage organizations face new compliance requirements to include sufficient essential community providers in their networks and must justify any failure to meet standards. This may increase administrative costs and network contracting expenses. Plans that cannot meet the standard risk non-approval by the Secretary.
Key Provisions
- MA plans must include a sufficient number and geographic distribution of essential community providers
- Plans must offer to contract with all essential community providers in their service area
- Payment to FQHCs must be consistent with existing Medicare payment requirements
- Plans not meeting the standard must submit justification or face non-approval
Evidence Chain:
This summary is generated from the full bill text using AI analysis. Expand "Detailed Analysis" below for identified beneficiaries/burden bearers.
At a Glance
What This Bill Does
Requires Medicare Advantage plans to include essential community providers (safety-net providers serving low-income and underserved populations) in their networks and meet network adequacy standards
Key Policy Areas
Healthcare, Medicare, Rural Health, Safety Net Programs
Primary Purpose
Requires Medicare Advantage plans to include essential community providers (safety-net providers serving low-income and underserved populations) in their networks and meet network adequacy standards
Policy Domains
Section 2 - Medicare Advantage Essential Community Providers
Identified Gains
Contextual inference, no direct clause citation- Low-income Medicare beneficiaries
- Rural Medicare beneficiaries
- Federally Qualified Health Centers
- Rural hospitals
- Mental health and substance use treatment facilities
- Indian Health Service facilities
- Ryan White HIV/AIDS Program facilities
Contextual inference, no direct clause citation
Identified Costs
Contextual inference, no direct clause citation- Medicare Advantage organizations
- Health insurance companies offering MA plans
Contextual inference, no direct clause citation
Sponsors
Legislative Progress
IntroducedMr. Cassidy (for himself and Mr. Luján) introduced the following …
Impact analysis is available but no clear stakeholder effects identified. View clause-level analysis →
Bill Structure & Actor Mappings
Who is "The Secretary" in each section?
- "the_secretary"
- → Secretary of Health and Human Services
Key Definitions
Terms defined in this bill
A provider that serves predominantly low-income, medically underserved individuals, including: Federally qualified health centers, Ryan White HIV/AIDS Program facilities, Indian Health Service facilities, various hospital types (disproportionate share, rural referral, sole community, critical access, cancer hospitals), mental health and substance use treatment facilities, STD clinics, TB clinics, hemophilia treatment centers, black lung clinics, and medicare-dependent small rural hospitals
We use a combination of our own taxonomy and classification in addition to large language models to assess meaning and potential beneficiaries. High confidence means strong textual evidence. Always verify with the original bill text.
Learn more about our methodology