REAL Health Providers Act
The REAL Health Providers Act (REAL Health Providers Act) would amend Medicare rules to require Medicare Advantage (MA) plans to maintain accurate, publicly available provider directories for specified MA plans starting in 2028. The bill sets strict updates and verification timelines, requires disclosure of key provider details, and imposes protections for enrollees when directory information is inaccurate (notably limiting out-of-network cost-sharing when a listed provider is not actually in-network). It also mandates annual accuracy analyses, a private-sector reporting requirement to CMS, a Government Accountability Office (GAO) study, and guidance from HHS to MA plans and providers to support directory accuracy and reduce administrative burden. A small early funding allocation would support these activities. In short, the bill aims to improve transparency and accuracy of MA provider directories, reduce patient confusion and financial risk from outdated or incorrect directory data, and increase oversight and measurement of directory quality over time.
Key Points
- 1Public, up-to-date provider directories: Beginning with plan year 2028, specified MA plans must maintain an accurate online provider directory with details such as name, specialty, contact info, address, whether accepting new patients, accessibility, language/cultural capabilities, and telehealth options.
- 2Regular verification and timely removal: The directory must be verified at least every 90 days (or at least annually for certain facilities as determined by the Secretary) and providers must be removed within 5 business days if they are no longer in-network.
- 3Cost-sharing protections for directory inaccuracies: If an enrollee receives services from a non-participating provider listed in the directory, the MA plan must apply the lower of (a) the in-network cost sharing that would have applied if the provider were in-network, or (b) the actual out-of-network cost sharing. Enrollees must be notified of these protections.
- 4Reporting and transparency: Starting in 2028, MA plans must annually conduct a provider directory accuracy analysis, generate an accuracy score using specified verification methods, and CMS must publish these scores in machine-readable form beginning in 2029.
- 5Oversight, analysis, and guidance: The bill requires a GAO study (to be completed by 2032) and mandates targeted guidance to MA plans and providers within 12 months of enactment to support directory accuracy and reduce administrative burden. It also requires a stakeholder meeting within 3 months and guidance on updating the National Plan and Provider Enumeration System (NPPES) for providers.
- 6Funding: A new appropriation of $4 million (FY 2026) is provided to CMS to implement the amendments.