S. 3750: Requiring Enhanced and Accurate Lists of Health Providers Act

This bill establishes new requirements for provider directories used in Medicare Advantage plans, aimed at ensuring that information about healthcare providers is accurate and up-to-date. Here’s a summary of the key components:

Short Title

The bill may be referred to as the Requiring Enhanced and Accurate Lists of Health Providers Act or the REAL Health Providers Act.

Provider Directory Requirements

Starting with plan year 2028, Medicare Advantage organizations must:

• Maintain a publicly accessible, accurate provider directory that includes essential information about providers.
• Verify the information in this directory at least every 90 days for most providers, or annually for certain facilities, updating as necessary.
• Indicate if they cannot verify a provider's information and must remove a provider from the directory within five business days if they are no longer part of the plan's network.

The directory should contain information that helps enrollees access covered benefits, such as:

• Provider name and specialty
• Contact information and location
• Availability to accept new patients
• Accommodations for disabilities
• Cultural and linguistic capabilities
• Telehealth services

Accountability for Directory Accuracy

The bill introduces protections for enrollees affected by inaccuracies in provider directories:

• If an enrollee receives service from a provider not participating in the network but listed in the directory, they should only pay the lower of the cost-sharing amount they would owe if the provider had been in-network or the standard out-of-network cost-sharing amount.
• Medicare Advantage organizations must notify enrollees about these cost-sharing protections and include the relevant information in their provider directories.

Required Analysis and Reporting

Starting in 2028, Medicare Advantage organizations must:

• Conduct an annual analysis of the accuracy of their provider directory information using a random sampling method.
• Submit a report of this analysis, including an accuracy score, to the Secretary of Health and Human Services.
• The Secretary will provide guidance on measurement methods that consider both the administrative burden and the importance of certain types of provider information.

Beginning in 2029, the results of these accuracy analyses, including the scores, must be made transparent and posted online by the Secretary.

Guidance on Maintaining Accurate Directories

The Secretary of Health and Human Services is required to:

• Hold public meetings to gather input on effective strategies for maintaining accurate provider directories, involving relevant stakeholders.
• Issue guidance based on this input, covering best practices, data sources for accuracy, and information inclusion for beneficiaries.
• Provide guidance to service providers on timely updates to their information in official systems.

Funding Provisions

The bill allocates $4 million for Fiscal Year 2026 to the Centers for Medicare & Medicaid Services (CMS) for implementing the new requirements.

Study and Report

The Comptroller General of the United States will conduct a study analyzing the implementation of these new requirements, focusing on:

• Utilization of cost-sharing protections
• Trends in provider directory accuracy
• Provider response rates to verification methods
• Administrative costs for both providers and Medicare Advantage organizations

A report with findings and recommendations is due by January 15, 2033.

Relevant Companies

• UNH - UnitedHealth Group: As a major insurer offering Medicare Advantage plans, could be significantly impacted by the new requirements to maintain accurate provider directories and ensure compliance with verification processes.
• ANTM - Anthem: As a leading health benefits company with Medicare Advantage offerings, would need to adapt its provider directory management practices under this bill.
• CNC - Centene Corporation: As a provider of Medicare Advantage plans, Centene may face operational changes to comply with the accuracy and verification requirements mandated by this legislation.