REAL Health Providers Act

Bill Number: H.R. 5281
Origin Chamber: House
Congress: 119th Congress, Session 1
Policy Area: Health
Status: Introduced
Latest Action: 2025-09-10: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Last Updated: 2026-02-26T18:25:51Z

AI-Generated Summary

Purpose of the Legislation

The REAL Health Providers Act (H.R. 5281) aims to improve the accuracy of provider directories in Medicare Advantage (MA) plans, which are private health insurance options under Medicare. It seeks to help enrollees (people enrolled in these plans) find in-network doctors and facilities more easily, reduce surprises in accessing care, and hold MA plan organizations accountable for outdated or incorrect information.

Key Provisions

Provider Directory Requirements (Effective 2028):
MA organizations must maintain an up-to-date, publicly available online provider directory for "specified MA plans" (network-based plans like HMOs or PPOs, and certain private fee-for-service plans that use provider contracts).
Directories must include key details about providers, such as name, specialty, contact information, office address, whether they accept new patients, accommodations for disabilities, language support, and telehealth options.
Organizations must verify directory information at least every 90 days (or every 12 months for hospitals and similar facilities, as set by the Secretary of Health and Human Services). If verification fails, they must note that the information might be outdated. Non-participating providers must be removed within 5 business days.

Cost-Sharing Protections for Enrollees (Effective 2028):
If an enrollee schedules an appointment based on the directory and the provider is listed but not actually in-network, the enrollee pays only the lower of: (1) the in-network cost-sharing amount, or (2) the actual cost-sharing that applies.
MA organizations must notify enrollees of these protections annually (before open enrollment), include them in directories, and mention them in explanations of benefits.

Accuracy Analysis and Reporting (Effective 2028):
MA organizations must annually analyze directory accuracy using a random sample of providers, focusing on high-inaccuracy specialties like mental health or substance use disorder treatment. They submit reports with an "accuracy score" to the Centers for Medicare & Medicaid Services (CMS) using methods specified by the Secretary (e.g., phone checks or public data).
CMS posts these scores publicly online starting in 2029 in a machine-readable format. Low-enrollment plans may be exempt.
$4 million is appropriated for fiscal year 2026 to CMS for implementation.

Guidance and Oversight:
Within 3 months of enactment, the Secretary holds a public stakeholder meeting to discuss best practices for accurate directories, including reducing administrative burdens through data standardization.
Within 12 months, the Secretary issues guidance to MA organizations on maintaining directories (e.g., using data sources, best practices with providers) and to Part B providers (doctors and suppliers under traditional Medicare) on updating their information in the National Plan and Provider Enumeration System (a national database for provider IDs).
The Government Accountability Office (GAO) must study implementation by 2032, analyzing cost-sharing use, accuracy trends (especially for mental health), administrative costs, and provider responses, then report to Congress with recommendations.

Significant Changes to Existing Law

Amends Section 1852(c) of the Social Security Act to add new requirements for directory maintenance, verification, and content in MA plans, building on existing rules for providing directories to enrollees.
Modifies Section 1852(d) to expand protections against cost-sharing for out-of-network care, adding a new clause for directory errors (previously limited to emergencies or urgent care).
Adds Section 1857(e)(6) requiring annual accuracy audits and reports, with public posting of scores (no prior federal mandate for such systematic checks in MA).
Updates Section 1851(d)(4) to require displaying accuracy scores in plan information provided to beneficiaries during enrollment.

These changes introduce mandatory verification timelines, penalties via cost-sharing relief, and transparency measures not previously required, shifting from voluntary to enforced accuracy.

Potential Impacts

On Citizens (Medicare Enrollees): Enrollees in specified MA plans (affecting millions) gain more reliable information to choose plans and providers, reducing unexpected costs and access barriers, especially for mental health care. This could improve care access but may not affect traditional Medicare users.
On Government Agencies: CMS faces new duties to specify verification methods, post scores, hold meetings, and issue guidance, supported by dedicated funding. The Secretary of Health and Human Services gains oversight tools. GAO conducts a one-time study. Overall, increases administrative workload but promotes program integrity.
On MA Organizations and Providers: Organizations incur costs for verification and reporting (offset by guidance on efficiency), with potential financial liability from cost-sharing protections. Providers benefit from clearer update processes but may face more frequent contacts.
On International Relations: No impacts, as this is domestic health policy.

Main Stakeholders Affected

Medicare Advantage Enrollees: Primary beneficiaries, gaining protections and transparency.
Medicare Advantage Organizations: Insurers like UnitedHealth or Humana, required to update systems and comply with audits.
Health Care Providers: Doctors, hospitals, and facilities in MA networks, involved in verification and data updates.
Federal Agencies: CMS and the Department of Health and Human Services for implementation and guidance; GAO for evaluation.
Patient Advocates and Insurers: Involved in stakeholder input, indirectly shaping practices.

Notable Legal, Constitutional, or Political Implications

Legal: Strengthens enforcement through contract requirements in MA plans and cost-sharing remedies, potentially leading to more disputes or audits if directories remain inaccurate. Relies on the Secretary's discretion for methods and waivers, allowing flexibility but risking inconsistency.
Constitutional: No direct challenges; aligns with Congress's authority over Social Security and interstate commerce in health care.
Political: Enhances accountability in the privatized Medicare Advantage program (which serves over half of Medicare beneficiaries), addressing bipartisan concerns about network adequacy and "ghost networks" (listed but unavailable providers). The GAO report could influence future reforms, and funding ensures startup without broad budget fights.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. Panetta, Jimmy [D-CA-19]

Cosponsors (8)

Rep. Murphy, Gregory F. [R-NC-3], Rep. Landsman, Greg [D-OH-1], Rep. Schneider, Bradley Scott [D-IL-10], Rep. Fitzpatrick, Brian K. [R-PA-1], Rep. Joyce, John [R-PA-13], Rep. Deluzio, Christopher R. [D-PA-17], Rep. Carson, André [D-IN-7], Rep. Auchincloss, Jake [D-MA-4]

Recent Actions

2025-09-10: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
2025-09-10: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
2025-09-10: Introduced in House
2025-09-10: Introduced in House

Bill Versions

Requiring Enhanced and Accurate Lists of Health Providers Act — issued 2025-09-10 — PDF (15 pages)