S 2793119th CongressIn Committee

Ensuring Access to Essential Providers Act of 2025

Introduced: Sep 11, 2025

Healthcare

Standard Summary

Comprehensive overview in 1-2 paragraphs

The Ensuring Access to Essential Providers Act of 2025 would overhaul Medicare Advantage (MA) network requirements by adding an “essential community provider” standard. MA organizations would have to include, in their service-area networks, a sufficient number and geographic distribution of essential community providers (ECPs) and offer to contract with them. These providers are primarily those serving low-income or medically underserved populations (for example, Federally Qualified Health Centers, Ryan White programs, Indian Health Service facilities, various hospitals, mental health facilities, and other designated providers). The bill also requires MA plans to pay Federally Qualified Health Centers (FQHCs) at rates consistent with existing Medicare rules and to justify any failure to meet the standard, with the Secretary able to disapprove plans that do not provide an adequate justification. The standard does not require coverage of any specific medical procedure, but it emphasizes access for populations in low-income, rural, or Health Professional Shortage Areas. The measure would be implemented through MA plan contract and annual plan-year processes.

Key Points

1MA essential community provider standard: The bill adds a new paragraph to require MA organizations to include an adequate number and geographic distribution of essential community providers in each plan’s service area and to offer to contract with every essential community provider in that area.
2Focus on underserved populations: The standard is designed to ensure reasonable, timely access for low-income individuals, rural residents, and those in Health Professional Shortage Areas, by requiring appropriate provider numbers and distribution.
3Justification and oversight: If an MA plan does not meet the standard, it must include a detailed justification and show how its network serves underserved populations and plans to move toward compliance before the next plan year; the Secretary can block plan approval if justification is insufficient.
4Payment to FQHCs: MA plans must pay Federally Qualified Health Centers at rates described in the bill (consistent with section 1857(e)(3)).
5Broad definition of essential community providers: The term includes FQHCs, Ryan White-supported facilities, Indian Health Service or tribal facilities, a wide range of hospitals (including rural and critical access types), mental health and substance use facilities, and other entities serving predominantly low-income or medically underserved individuals. The Secretary is empowered to designate additional providers as ECPs.

Impact Areas

Primary group/area affected- Medicare Advantage enrollees, especially those who are low-income, live in rural areas, or reside in Health Professional Shortage Areas, who may gain improved access to a broader set of community-based providers within MA plan networks.Secondary group/area affected- MA plans and their network contracting operations, which would need to recruit and contract with a larger set of ECPs, adjust network development, and ensure geographic coverage meets the standard.Additional impacts- Financial and administrative implications for MA plans due to required payments to FQHCs at specified rates and the need to maintain more diverse provider networks.- Increased regulatory oversight by the Secretary, including potential disapproval of MA plans that cannot justify not meeting the standard.- Aligns MA network design with broader federal efforts to bolster access to care in underserved communities; could interact with other federal programs and provider classifications (e.g., ACA-based designations) as the law references other existing standards.

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