Ensuring Access to Essential Providers Act of 2025
The Ensuring Access to Essential Providers Act of 2025 would expand Medicare Advantage (MA) plan requirements to ensure greater access to care for underserved populations by obligating MA plans to include and contract with a broad set of essential community providers (ECPs) within each plan’s service area. The bill adds an ECP standard to the MA network adequacy rules, requiring MA plans to incorporate a defined level of ECPs, maintain geographic distribution to serve low-income and rural residents and health professional shortage areas, and ensure payment terms to federally qualified health centers (FQHCs) align with current Medicare rules. If a plan cannot meet the standard, it must justify the shortfall and show how it will improve access before the next plan year. The Secretary would oversee designations and the adequacy criteria, and plans must not be compelled to cover specific procedures beyond what is otherwise required. In short, the bill aims to make MA networks more inclusive of safety-net and underserved providers, with explicit obligations on contracting, access, and payment to certain ECPs, while preserving plan flexibility regarding medical procedures.
Key Points
- 1Creates an essential community provider standard for MA plans (within their service areas) that MA organizations must meet to be considered compliant.
- 2Requirements to meet the standard:
- 3- Include an amount of available ECPs in the plan’s network and offer to contract with each ECP in the service area.
- 4- Ensure sufficient number and geographic distribution of ECPs so low-income individuals, people in rural areas, and those in health professional shortage areas have reasonable and timely access to a broad range of ECPs.
- 5- Meet payment requirements to federally qualified health centers (FQHCs) consistent with current Medicare payment rules.
- 6If an MA plan does not meet the standard, it must provide:
- 7- A justification explaining why and a narrative showing how the plan’s network meets the needs of low-income and shortage-area enrollees and will move toward meeting the standard before the next plan year.
- 8- The Secretary may deny approval of a plan if the justification is insufficient.
- 9Payment to FQHCs: MA plans must pay FQHCs in amounts consistent with the Medicare payment framework described in Section 1857(e)(3).
- 10Clarification: The standard cannot be read to require MA plans to cover a specific medical procedure.
- 11Definition of essential community provider (ECP): A broad, enumerated list of providers serving predominantly low-income, medically underserved individuals, including:
- 12- Federally Qualified Health Centers (and similar clinics)
- 13- Ryan White HIV/AIDS Program facilities
- 14- Indian Health Service facilities, tribal organizations, and urban Indian organizations
- 15- Hospitals (various types, including rural, sole community, disproportionate share, critical access, cancer centers)
- 16- Mental health or substance use treatment facilities
- 17- Other entities serving underserved populations (e.g., certain federally funded programs, tuberculosis clinics, hemophilia centers, black lung clinics, medicare-dependent rural hospitals)
- 18- Any provider deemed appropriate by the Secretary (potentially adding others based on 1311(c)(1)(C) of the ACA)
- 19Enforcement and oversight: The Secretary determines whether a plan’s justification is adequate and can block plan approval if it is not.