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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 7708 Introduced in House (IH)]

<DOC>

118th CONGRESS
  2d Session
                                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

                             March 15, 2024

 Mr. Panetta (for himself, Mr. Murphy, Ms. Kuster, Mr. Schneider, and 
 Mr. Fitzpatrick) introduced the following bill; which was referred to 
 the Committee on Ways and Means, and in addition to the Committee on 
Energy 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 maintain an accurate 
              provider directory, 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. REQUIRING ENHANCED & ACCURATE LISTS OF (REAL) HEALTH 
              PROVIDERS ACT.

    (a) In General.--Section 1852(c) of the Social Security Act (42 
U.S.C. 1395w-22(c)) is amended--
            (1) in paragraph (1)(C)--
                    (A) by striking ``plan, and any'' and inserting 
                ``plan, any''; and
                    (B) by inserting before the period at the end: ``, 
                and, in the case of a network-based plan (as defined in 
                paragraph (3)(C)), for plan year 2026 and subsequent 
                plan years, the information described in paragraph 
                (3)(B)''; and
            (2) by adding at the end the following new paragraph:
            ``(3) Provider directory accuracy.--
                    ``(A) In general.--For plan year 2026 and 
                subsequent plan years, each MA organization offering a 
                network-based plan (as defined in subparagraph (C)) 
                shall, for each network-based plan offered by the 
                organization--
                            ``(i) maintain, on a publicly available 
                        internet website, an accurate provider 
                        directory that includes the information 
                        described in subparagraph (B);
                            ``(ii) not less frequently than once every 
                        90 days (or, in the case of a hospital or any 
                        other facility determined appropriate by the 
                        Secretary, at a lesser frequency specified by 
                        the Secretary but in no case less frequently 
                        than once every 12 months), verify the provider 
                        directory information of each provider listed 
                        in such directory and, if applicable, update 
                        such provider directory information;
                            ``(iii) if the organization is unable to 
                        verify such information with respect to a 
                        provider, include in such directory an 
                        indication that the information of such 
                        provider may not be up to date;
                            ``(iv) remove a provider from such 
                        directory within 5 business days if the 
                        organization determines that the provider is no 
                        longer a provider participating in the network 
                        of such plan; and
                            ``(v) meet such other requirements as the 
                        Secretary may specify.
                    ``(B) Provider directory information.--The 
                information described in this subparagraph is 
                information enrollees may need to access covered 
                benefits from a provider with which such organization 
                offering such plan has an agreement for furnishing 
                items and services covered under such plan such as 
                name, specialty, contact information, primary office or 
                facility address, whether the provider is accepting new 
                patients, accommodations for people with disabilities, 
                cultural and linguistic capabilities, and telehealth 
                capabilities.
                    ``(C) Network-based plan.--In this paragraph, the 
                term `network-based plan' has the meaning given that 
                term in subsection (d)(5)(C), except such term includes 
                a Medicare Advantage private fee-for-service plan, as 
                determined appropriate by the Secretary.''.
    (b) Accountability for Provider Directory Accuracy.--
            (1) Cost sharing for services furnished based on reliance 
        on incorrect provider directory information.--Section 1852(d) 
        of the Social Security Act (42 U.S.C. 1395w-22(d)) is amended--
                    (A) in paragraph (1)(C)--
                            (i) in clause (ii), by striking ``or'' at 
                        the end;
                            (ii) in clause (iii), by striking the 
                        semicolon at the end and inserting ``, or''; 
                        and
                            (iii) by adding at the end the following 
                        new clause:
                            ``(iv) the services are furnished by a 
                        provider that is not participating in the 
                        network of a network-based plan (as defined in 
                        subsection (c)(3)(C)) but is listed in the 
                        provider directory of such plan on the date on 
                        which the appointment is made, as described in 
                        paragraph (7)(A);''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(7) Cost sharing for services furnished based on reliance 
        on incorrect provider directory information.--
                    ``(A) In general.--For plan year 2026 and 
                subsequent plan years, if an enrollee is furnished an 
                item or service by a provider that is not participating 
                in the network of a network-based plan (as defined in 
                subsection (c)(3)(C)) but is listed in the provider 
                directory of such plan (as required to be provided to 
                an enrollee pursuant to subsection (c)(1)(C)) on the 
                date on which the appointment is made, and if such item 
                or service would otherwise be covered under such plan 
                if furnished by a provider that is participating in the 
                network of such plan, the MA organization offering such 
                plan shall ensure that the enrollee is only responsible 
                for the amount of cost sharing that would apply if such 
                provider had been participating in the network of such 
                plan.
                    ``(B) Notification requirement.--For plan year 2026 
                and subsequent plan years, each MA organization that 
                offers a network-based plan shall--
                            ``(i) notify enrollees of their cost-
                        sharing protections under this paragraph and 
                        make such notifications, to the extent 
                        practicable, by not later than the first day of 
                        an annual, coordinated election period under 
                        section 1851(e)(3) with respect to a year;
                            ``(ii) include information regarding such 
                        cost-sharing protections in the provider 
                        directory of each network-based plan offered by 
                        the MA organization.; and
                            ``(iii) notify enrollees of their cost-
                        sharing protections under this paragraph in an 
                        explanation of benefits.''.
            (2) Required provider directory accuracy analysis and 
        reports.--
                    (A) In general.--Section 1857(e) of the Social 
                Security Act (42 U.S.C. 1395w-27(e)) is amended by 
                adding at the end the following new paragraph:
            ``(6) Provider directory accuracy analysis and reports.--
                    ``(A) In general.--Beginning with plan years 
                beginning on or after January 1, 2026, subject to 
                subparagraph (C), a contract under this section with an 
                MA organization shall require the organization, for 
                each network-based plan (as defined in section 
                1852(c)(3)(C)) offered by the organization, to 
                annually--
                            ``(i) conduct an analysis estimating the 
                        accuracy of the provider directory of such plan 
                        using a sample of providers included in such 
                        provider directory (including provider 
                        specialties with high inaccuracy rates of 
                        provider directory information, such as 
                        providers specializing in mental health or 
                        substance use disorder treatment, as determined 
                        by the Secretary); and
                            ``(ii) submit a report to the Secretary 
                        containing the results of such analysis, 
                        including an accuracy score for such provider 
                        directory (as determined using a methodology 
                        specified by the Secretary under subparagraph 
                        (B)(i)), and other information required by the 
                        Secretary.
                    ``(B) Determination of accuracy score.--
                            ``(i) In general.--The Secretary shall 
                        specify methodologies for MA plans to use in 
                        estimating the accuracy of the provider 
                        directory information of such plans and 
                        determining the accuracy score for the plan's 
                        provider directory.
                            ``(ii) Considerations.--In carrying out 
                        clause (i), the Secretary shall take into 
                        consideration--
                                    ``(I) data sources maintained by MA 
                                organizations;
                                    ``(II) publicly available data 
                                sets;
                                    ``(III) the administrative burden 
                                on plans and providers; and
                                    ``(IV) the relative importance of 
                                certain provider directory information 
                                on enrollee ability to access care.
                    ``(C) Exception.--The Secretary may waive the 
                requirements of this paragraph in the case of a 
                network-based plan with low enrollment (as defined by 
                the Secretary).
                    ``(D) Transparency.--Beginning with plan years 
                beginning on or after January 1, 2027, the Secretary 
                shall post accuracy scores (as reported under 
                subparagraph (A)(ii)), in a machine readable file, on 
                the internet website of the Centers for Medicare & 
                Medicaid Services.
                    ``(E) Implementation.--The Secretary shall 
                implement this paragraph through notice and comment 
                rulemaking.''.
                    (B) Provision of information to beneficiaries.--
                Section 1851(d)(4) of the Social Security Act (42 
                U.S.C. 1395w-21(d)(4)) is amended by adding at the end 
                the following new subparagraph:
                    ``(F) Provider directory.--Beginning with plan 
                years beginning on or after January 1, 2027, the 
                accuracy score of the plan's provider directory (as 
                reported under section 1857(e)(6)(A)(ii)) on the plan's 
                provider directory.''.
                    (C) Funding.--In addition to amounts otherwise 
                available, there is appropriated to the Centers for 
                Medicare & Medicaid Services Program Management 
                Account, out of any money in the Treasury not otherwise 
                appropriated, $1,000,000 for fiscal year 2025, to 
                remain available until expended, to carry out the 
                amendments made by this paragraph.
            (3) GAO study and report.--
                    (A) Analysis.--The Comptroller General of the 
                United States (in this paragraph referred to as the 
                ``Comptroller General'') shall conduct study of the 
                implementation of the amendments made by paragraphs (1) 
                and (2). To the extent data are available and reliable, 
                such study shall include an analysis of--
                            (i) the use of protections required under 
                        section 1852(d)(7) of the Social Security Act, 
                        as added by paragraph (1);
                            (ii) the provider directory accuracy scores 
                        trends under section 1857(e)(6)(A)(ii) of the 
                        Social Security Act (as added by paragraph 
                        (2)(A)), both overall and among providers 
                        specializing in mental health or substance 
                        disorder treatment;
                            (iii) provider response rates by plan 
                        verification methods; and
                            (iv) other items determined appropriate by 
                        the Comptroller General.
                    (B) Report.--Not later than January 15, 2031, the 
                Comptroller General shall submit to Congress a report 
                containing the results of the study conducted under 
                subparagraph (A), together with recommendations for 
                such legislation and administrative action as the 
                Comptroller General determines appropriate.
    (c) Guidance on Maintaining Accurate Provider Directories.--
            (1) Stakeholder meeting.--
                    (A) In general.--Not later than 3 months after the 
                date of enactment of this Act, the Secretary of Health 
                and Human Services (referred to in this subsection as 
                the ``Secretary'') shall hold a public stakeholder 
                meeting to receive input on approaches for maintaining 
                accurate provider directories for Medicare Advantage 
                plans under part C of title XVIII of the Social 
                Security Act (42 U.S.C. 1395w-21 et seq.), including 
                input on approaches for reducing administrative burden 
                such as data standardization and best practices to 
                maintain provider directory information.
                    (B) Participants.--Participants of the meeting 
                under subparagraph (A) shall include representatives 
                from the Centers for Medicare & Medicaid Services and 
                the Office of the National Coordinator for Health 
                Information Technology, health care providers, 
                companies that specialize in relevant technologies, 
                health insurers, and patient advocates.
            (2) Guidance to medicare advantage organizations.--Not 
        later than 12 months after the date of enactment of this Act, 
        the Secretary shall issue guidance to Medicare Advantage 
        organizations offering Medicare Advantage plans under part C of 
        title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et 
        seq.) on maintaining accurate provider directories for such 
        plans, taking into consideration input received during the 
        stakeholder meeting under paragraph (1). Such guidance may 
        include the following, as determined appropriate by the 
        Secretary:
                    (A) Best practices for Medicare Advantage 
                organizations on how to work with providers to maintain 
                the accuracy of provider directories and reduce 
                provider and Medicare Advantage organization burden 
                with respect to maintaining the accuracy of provider 
                directories.
                    (B) Information on data sets and data sources with 
                information that could be used by Medicare Advantage 
                organizations to maintain accurate provider 
                directories.
                    (C) Approaches for utilizing data sources 
                maintained by Medicare Advantage organizations and 
                publicly available data sets to maintain accurate 
                provider directories.
                    (D) Information to be included in the provider 
                directory that may be useful for Medicare beneficiaries 
                to assess plan networks when selecting a plan and 
                accessing providers participating in plan networks 
                during the plan year.
            (3) Guidance to part b providers.--Not later than 12 months 
        after the date of enactment of this Act, the Secretary shall 
        issue guidance to providers of services and suppliers who 
        furnish items or services for which benefits are available 
        under part B of title XVIII of the Social Security Act (42 
        U.S.C. 1395j et seq.) on when to update the National Plan and 
        Provider Enumeration System regarding any information changes.
                                 <all>
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