REAL Health Providers Act
The REAL Health Providers Act would tighten how Medicare Advantage (MA) plans manage and share information about which providers are in-network. Starting in plan year 2028, specified MA plans must maintain an accurate, publicly available provider directory online and verify its accuracy at least every 90 days (with some flexibility for certain facilities). If a listed provider is no longer in-network, patients who use that provider would receive cost-sharing protections, limiting their out-of-pocket costs to the in-network level or the plan’s usual amount, whichever is lower. The bill also requires MA organizations to conduct annual accuracy analyses of their provider directories, report results to the Secretary of Health and Human Services, and publish accuracy scores starting in 2029. It creates a data-driven push to improve directory accuracy, includes funding for CMS to implement the changes, and directs a GAO study to assess how well the program works and its costs. Finally, the law would require the Secretary to hold stakeholder meetings and issue guidance to MA plans and to providers (and to help keep the national provider registry (NPPES) up to date). In short, the bill aims to increase transparency, reduce surprise bills stemming from inaccurate provider directories, and provide ongoing oversight of directory accuracy for certain Medicare Advantage plans.
Key Points
- 1Provider directory requirements for specified MA plans
- 2- Starting with plan year 2028, MA organizations offering specified MA plans must maintain a publicly accessible online provider directory that includes defined information (name, specialty, contact info, address, whether accepting new patients, disability and language accommodations, telehealth capabilities, etc.).
- 3- The directory must be updated and verified at least every 90 days (or more frequently as the Secretary allows for certain facilities), with removals of non-participating providers completed within 5 business days.
- 4Cost-sharing protections when relying on an incorrect directory
- 5- If a patient receives services from a non-participating provider who is listed in the plan’s directory at the time of the appointment, the enrollee’s cost sharing must be limited to the in-network amount (or the standard amount, whichever is lower).
- 6- Plans must notify enrollees about these protections, include them in the provider directory, and explain them in explanations of benefits (EOBs).
- 7Provider directory accuracy analysis, reporting, and transparency
- 8- Beginning in plan years after January 1, 2028, MA contracts must require annual analysis of directory accuracy using a random sample of providers and report results, including an accuracy score, to the Secretary.
- 9- The Secretary will specify methods for verifying accuracy and a methodology for scoring accuracy, with a process to consider administrative burden and patient access.
- 10- Starting in 2029, CMS must post the accuracy scores in a machine-readable format on its website, and the accuracy score must be shown prominently in the plan’s directory listing.
- 11- A small funding provision (beyond existing funding) appropriates $4 million for fiscal year 2026 to CMS to implement these amendments.
- 12Oversight, guidance, and studies
- 13- The Comptroller General (GAO) will study the implementation, including cost-sharing protections, accuracy trends (especially for mental health and substance use provider types), provider response rates, and administrative costs, with a final report due by January 15, 2032.
- 14- The Secretary must hold a stakeholder meeting within 3 months of enactment to gather input on maintaining accurate directories and reducing burden, followed by issuing guidance to MA organizations within 12 months, covering best practices, data sources, and how directories help beneficiaries.
- 15- Guidance to providers (Part B) on updating information in the National Plan and Provider Enumeration System (NPPES) is required within 12 months.
- 16Scope and definitions
- 17- “Specified MA plan” covers network-based MA plans and certain Medicare Advantage private fee-for-service plans that meet access standards.
- 18- Provisions apply to plan years 2028 onward, with related reporting and guidance phased in accordingly.