The REAL Health Providers Act requires Medicare Advantage (MA) organizations offering network-based plans and certain private fee‑for‑service MA plans to maintain publicly accessible, routinely verified provider directories and to flag or remove unverifiable entries. It sets specific operational rules — a verification cadence, an indicator for unverified providers, and a five‑business‑day removal requirement — and expands the directory fields plans must publish (including accessibility and telehealth capabilities).
The bill also creates financial accountability for inaccurate directories: when an enrollee relies on directory information to schedule care and the listed provider is not in‑network, the enrollee pays whichever is lower between the in‑network cost sharing and the otherwise applicable amount. CMS must collect annual accuracy scores from plans, publish them in machine‑readable form, and the GAO will study implementation and costs.
The law directs CMS to convene stakeholders and issue guidance, and it includes a modest appropriation to support implementation.
At a Glance
What It Does
Imposes new directory content and maintenance rules on MA plans, requires periodic provider verification (typically every 90 days), mandates plan reporting of an objectively calculated accuracy score, and creates enrollee cost‑sharing protections when directories are wrong.
Who It Affects
Network‑based Medicare Advantage plans and certain MA private fee‑for‑service plans; MA organizations’ provider network teams; Part B providers and small practices that must keep enrollment/NPIs current; CMS operations and health IT vendors that supply directory services.
Why It Matters
The bill changes how beneficiaries evaluate and use MA networks by making directory accuracy auditable and publicly comparable, shifts some financial consequences of bad data off beneficiaries, and forces plans and providers to invest in ongoing directory maintenance and verification workflows.
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What This Bill Actually Does
The bill adds enforceable obligations for Medicare Advantage organizations to keep online provider directories accurate and actionable for beneficiaries. Plans must publish expanded data fields — such as whether a clinician is accepting new patients, accessibility accommodations, cultural/linguistic capabilities, and telehealth availability — and keep that information viewable on a public website.
The goal is to make directories usable when beneficiaries choose plans and schedule care.
Plans must verify directory entries at least once every 90 days for typical providers; the Secretary can allow a longer interval (but no less often than annually) for certain facilities like hospitals. When a plan cannot verify a provider’s details, the plan must display a clear indication that the information may be out of date.
If the plan determines a provider has left the network, it must remove that provider from the directory within five business days.To give beneficiaries a financial backstop, the bill requires plans to limit enrollee cost sharing when a person schedules care relying on directory information that later proves incorrect. Specifically, if an enrollee receives covered services from a listed but non‑participating provider, the enrollee owes the lesser of the in‑network cost‑sharing amount or the amount that would otherwise apply.
Plans must notify enrollees about this protection (including in the provider directory and in the first explanation of benefits each plan year) and include the information during open enrollment communications.The Secretary must also require plans to conduct annual, sample‑based analyses estimating directory accuracy and report an accuracy score to CMS; CMS will publish those scores in a machine‑readable format. The bill directs CMS to convene public stakeholder meetings and issue guidance on best practices and acceptable verification methods within defined timeframes, and it funds CMS implementation with a one‑time appropriation.
Finally, the Comptroller General will study the law’s effects and report back with recommendations to Congress.
The Five Things You Need to Know
Plans must verify provider directory information at least every 90 days for most providers and no less frequently than once every 12 months for certain facilities designated by HHS.
If a plan cannot verify a provider, the directory must display an explicit indicator that the provider’s information may be out of date; plans must remove providers found to be out of network within five business days.
When an enrollee schedules care based on directory information and the listed provider is actually out‑of‑network, the MA organization must ensure the enrollee pays the lesser of the in‑network cost‑sharing amount or the otherwise applicable cost sharing.
MA organizations must perform an annual, sample‑based accuracy analysis (including targeted sampling of specialties with historically high inaccuracy rates such as behavioral health), report an accuracy score to CMS, and CMS will publish those scores in machine‑readable form beginning for plan years after 2029.
The bill requires CMS stakeholder meetings and guidance (6–18 month windows after enactment), appropriates $4 million to CMS for implementation, and directs the GAO to report on outcomes and costs by January 15, 2033.
Section-by-Section Breakdown
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Mandatory public directories, verification cadence, and removal rule
This provision establishes the core operational duties for MA organizations: publish an online provider directory with expanded fields and verify entries on a regular cadence. The verification default is every 90 days for most providers, with a Secretary‑approved exception (no less often than yearly) for hospitals or similar facilities. The section requires plans to flag unverifiable listings and to remove providers within five business days when they are confirmed out of network. Practically, plans will need processes for provider outreach, a record‑keeping trail of verification attempts, and integration between network management systems and publicly facing websites.
Expanded directory fields to aid access and plan selection
The bill specifies a non‑exhaustive set of fields plans must include: specialty, contact info, primary office addresses, accepting‑new‑patients status, disability accommodations, cultural/linguistic capabilities, and telehealth offerings. That elevates functional access data (not just names and addresses), pushing plans toward richer, standardized data models and increasing the value of directories for beneficiaries evaluating networks and scheduling care.
Financial protection when directories are wrong
Amendments to the cost‑sharing rules create a remedy for beneficiaries who rely on incorrect directory listings: the enrollee’s financial liability is capped at the lower of the in‑network cost share or the provider’s otherwise applicable charge. The provision also requires plans to notify enrollees of this protection at enrollment, in the provider directory, and on the first EOB each year. This changes the incentives for plans and may increase billing disputes routed to plan customer service and appeals processes.
Annual sample‑based accuracy scoring and CMS publication
CMS must require plans to conduct an annual, random‑sample analysis to estimate directory accuracy, with targeted oversampling of specialties prone to inaccuracies (the bill cites mental health/substance use disorder providers as an example). CMS will define acceptable verification methods and scoring methodologies that weigh administrative burden and access implications. Reported accuracy scores must be submitted to CMS and, beginning in plan years after 2029, published in a machine‑readable file for public and market analysis.
Prominent display of accuracy score in directories
This amendment mandates that a plan’s provider directory prominently display the CMS‑reported accuracy score for specified MA plans. The change is meant to surface a plan‑level quality metric at the moment beneficiaries use directories, enabling more informed plan selection and easier comparisons across plans.
Implementation support, timelines, and evaluation
The bill requires HHS to convene a public stakeholder meeting within six months and to issue guidance to plans within 18 months on best practices, data sources, and burden‑reducing standardization; CMS must also issue guidance to Part B providers within 12 months about updating national provider enrollment systems. The statute appropriates $4 million for CMS implementation and tasks the GAO with a comprehensive study of implementation effects, including cost and provider response rates, with a report due to Congress by January 15, 2033.
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Who Benefits
- Medicare Advantage enrollees — gain clearer, more actionable directories and a financial backstop when directories are wrong, reducing unexpected out‑of‑network cost exposure when scheduling care.
- People with disabilities and non‑English speakers — the requirement to list accessibility and cultural/linguistic capabilities makes it easier to identify providers able to meet specific access needs and accommodations.
- Consumer and patient advocates — will obtain machine‑readable accuracy scores and richer directory fields to monitor plan performance and advocate for beneficiaries in enrollment and disputes.
Who Bears the Cost
- Medicare Advantage organizations — must build verification workflows, integrate data feeds, perform annual accuracy analyses, and absorb customer service and potential higher payments when correcting enrollee claims.
- Individual providers and small practices — face administrative burden to respond to verification requests and to keep enrollment/NPPES records current; smaller offices may lack staff for frequent updates.
- CMS and federal IT systems — must develop scoring methodologies, host and publish machine‑readable files, run stakeholder processes, and oversee compliance with only a modest one‑time appropriation, creating a potential funding and capacity gap.
Key Issues
The Core Tension
The central dilemma is balancing beneficiary protection against the real cost and operational burden of maintaining near‑perfect directories: stronger protections and frequent verification reduce surprise costs and improve plan comparability, but they shift substantial administrative work (and some financial exposure) onto plans, providers, and a CMS oversight system that the bill funds only modestly — forcing choices about verification methods and enforcement that will shape whether the policy helps beneficiaries in practice or simply creates paperwork and contestable scores.
The bill confronts a practical trade‑off between better data and administrative cost. Frequent verification (every 90 days) will improve freshness but requires substantial operational capacity: plans must track outreach attempts, store verification evidence, and reconcile multiple data sources.
That burden falls partly on providers, which could see increased administrative contacts and potential penalties in practice (for example, through no‑longer‑listed providers losing patient referrals). HHS’s forthcoming guidance and the Secretary’s choices on acceptable verification methods will determine how burdens scale — telephonic verification is staff‑intensive, whereas electronic matches to authoritative datasets are dependent on the quality of those datasets.
Another unresolved issue is enforcement and incentives. The statute limits enrollees’ financial exposure but does not prescribe civil monetary penalties or explicit sanctions for plans with persistently low accuracy scores, leaving CMS to use contract remedies under section 1857 and public shaming via published scores as the primary levers.
The sample‑based accuracy scoring methodology will be highly consequential: choices about sample size, specialty oversampling, and what counts as a ‘‘verified’’ field can materially change plan scores and provider behavior. Finally, the low‑enrollment waiver and Secretary discretion over facility verification cadence create potential avenues for uneven implementation or gaming by plans seeking to avoid onerous verification for certain provider types.
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