Requiring Enhanced and Accurate Lists of (real) Health Providers Act
Section 6220 · Sec. 6220 ·
What this chapter is about
This part is about the lists of doctors that private Medicare plans publish. From plan year 2028 a plan must keep the list right, check it every 90 days, and drop a doctor within five business days of leaving. A patient who relied on a wrong listing pays only the in-network share. Plans must score their own lists and the scores go public.
The document says “shall”Who acts: Medicare Advantage organizationsHow: statuteSec. 6220 in the PDF
What the document says
“maintain, on a publicly available internet website, an accurate provider directory that includes the information described in subparagraph (B);”
Section 6220 adds a new paragraph (3) to section 1852(c) of the Social Security Act. For plan year 2028 and later, each Medicare Advantage organization offering a specified MA plan must keep an accurate provider directory on a publicly available website for each such plan.
What the document actually says
“maintain, on a publicly available internet website, an accurate provider directory that includes the information described in subparagraph (B);”
That sentence, in plain words
The plan must keep a list of its doctors on a public website. The list must be right. It must hold the facts named below.
What this is about
A plan pays less, or nothing, for a doctor outside its group. So a patient checks the list first. A wrong list can cost that patient money.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Medicare Advantage organizationsHow: statuteSec. 6220 in the PDF
What the document says
“not less frequently than once every 90 days (or, in the case of a hospital or any other facility determined appropriate by the Secretary, at a lesser frequency specified by the Secretary but in no case less frequently than once every 12 months), verify the provider directory information of each provider listed in such directory and, if applicable, update such information;”
The new paragraph requires the organization to verify and, where needed, update each provider's directory information at least once every 90 days. For a hospital or other facility the Secretary finds appropriate, the Secretary may set a lower frequency, but never less often than once every 12 months.
What the document actually says
“not less frequently than once every 90 days (or, in the case of a hospital or any other facility determined appropriate by the Secretary, at a lesser frequency specified by the Secretary but in no case less frequently than once every 12 months), verify the provider directory information of each provider listed in such directory and, if applicable, update such information;”
That sentence, in plain words
At least once every 90 days the plan must check each doctor on the list. For a hospital the health chief may allow a longer gap, but not more than a year.
What this is about
Doctors move, retire, or leave a plan. A list goes stale fast. A set check keeps it close to true.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Medicare Advantage organizationsHow: statuteSec. 6220 in the PDF
What the document says
“remove a provider from such directory within 5 business days if the organization determines that the provider is no longer a provider participating in the network of such plan.”
The new paragraph also requires the organization, where it cannot verify a provider's information, to mark the entry as possibly out of date, and to remove a provider within five business days of determining that the provider is no longer in the plan's network.
What the document actually says
“remove a provider from such directory within 5 business days if the organization determines that the provider is no longer a provider participating in the network of such plan.”
That sentence, in plain words
If a doctor leaves the plan's group, the plan must take that doctor off the list. It has five work days to do it.
What this is about
A plan that cannot reach a doctor must say so on the list. That warns the patient. A doctor who has left must come off.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
“The information described in this subparagraph is information enrollees may need to access covered benefits from a provider with which such organization offering such plan has an agreement for furnishing items and services covered under such plan, such as name, specialty, contact information, primary office or facility addresses where items or services are furnished, whether the provider is accepting new patients”
The new paragraph defines provider directory information as what enrollees may need to get covered benefits from a provider under agreement with the plan. It names as examples the provider's name, specialty, contact information, primary office or facility addresses, whether the provider is accepting new patients, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.
What the document actually says
“The information described in this subparagraph is information enrollees may need to access covered benefits from a provider with which such organization offering such plan has an agreement for furnishing items and services covered under such plan, such as name, specialty, contact information, primary office or facility addresses where items or services are furnished, whether the provider is accepting new patients”
That sentence, in plain words
The list must carry what a patient needs to get care. That means a name and a field of work. It means how to get in touch and where the office is. It says whether the doctor takes new patients.
What this is about
The list also shows how a person with a disability can get in. It shows what languages are spoken. It shows if care by screen is on offer.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
“``(C) Specified ma plan.--In this paragraph, the term `specified MA plan' means--
``(i) a network-based plan (as defined in subsection (d)(5)(C)); or”
The new paragraph defines specified MA plan as a network-based plan as defined in section 1852(d)(5)(C), or a Medicare Advantage private fee-for-service plan under section 1859(b)(2) that meets the access standards in subsection (d)(4), in whole or in part, through contracts or agreements.
What the document actually says
“``(C) Specified ma plan.--In this paragraph, the term `specified MA plan' means--
``(i) a network-based plan (as defined in subsection (d)(5)(C)); or”
That sentence, in plain words
In this part, the words specified MA plan mean one of two kinds of plan. The first is a plan built on a group of doctors.
What this is about
The letters MA stand for a private plan that stands in for the public one. The rules here cover only plans that work through a group of doctors.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Medicare Advantage organizationsHow: statuteSec. 6220 in the PDF
What the document says
“the MA organization offering such plan shall ensure that the enrollee is only responsible for the lesser of--
``(i) the amount of cost sharing that would apply if such provider had been participating in the network of such plan; or
``(ii) the amount of cost sharing that would otherwise apply (without regard to this subparagraph).”
Section 6220 adds a new paragraph (7) to section 1852(d) of the Social Security Act. For plan year 2028 and later, where an enrollee in a specified MA plan is served by a provider outside the network who was listed in the directory on the date the appointment was made, and the item or service would have been covered in network, the organization must ensure the enrollee pays only the lesser of the in-network cost sharing or what would otherwise apply.
What the document actually says
“the MA organization offering such plan shall ensure that the enrollee is only responsible for the lesser of--
``(i) the amount of cost sharing that would apply if such provider had been participating in the network of such plan; or
``(ii) the amount of cost sharing that would otherwise apply (without regard to this subparagraph).”
That sentence, in plain words
The plan must make sure the patient pays the smaller of two amounts. One is what a doctor in the group would cost. The other is what would be charged anyway.
What this is about
The date that counts is the day the visit was booked. If the list was wrong that day, the patient does not pay for the mistake.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Medicare Advantage organizationsHow: statuteSec. 6220 in the PDF
What the document says
“notify enrollees of their cost-sharing protections under this paragraph and make such notifications, to the extent practicable, by not later than the first day of an annual, coordinated election period under section 1851(e)(3) with respect to a year;”
For plan year 2028 and later, an organization offering a specified MA plan must notify enrollees of the cost sharing protection, so far as practicable by the first day of the annual coordinated election period, include information about it in the plan's provider directory, and notify enrollees of it in the first explanation of benefits issued in a plan year.
What the document actually says
“notify enrollees of their cost-sharing protections under this paragraph and make such notifications, to the extent practicable, by not later than the first day of an annual, coordinated election period under section 1851(e)(3) with respect to a year;”
That sentence, in plain words
The plan must tell people signed up about this protection. It should do so by the first day of the yearly sign-up window.
What this is about
The plan must also put it on the doctor list. And it must put it in the first benefits notice of the year. That makes three places.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Medicare Advantage organizations, Secretary of Health and Human ServicesHow: statuteSec. 6220 in the PDF
What the document says
“Conduct an analysis estimating the accuracy of the provider directory information of such plan using a random sample of providers included in such provider directory as follows:”
Section 6220 adds a new paragraph (6) to section 1857(e) of the Social Security Act. For plan years beginning on or after January 1, 2028, a contract with a Medicare Advantage organization must require an annual analysis of directory accuracy using a random sample of listed providers, and a report to the Secretary with an accuracy score. The sample must include a random sample of each specialty with a high inaccuracy rate relative to others, as the Secretary determines, and one such specialty may be providers specializing in mental health or substance use disorder treatment.
What the document actually says
“Conduct an analysis estimating the accuracy of the provider directory information of such plan using a random sample of providers included in such provider directory as follows:”
That sentence, in plain words
The plan must check how right its doctor list is. It does that by picking names from the list at random.
What this is about
A score puts a number on how right the list is. Fields where the list is often wrong get looked at more. Mental health may be one of them.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6220 in the PDF
What the document says
“The Secretary shall specify plan verification methods, such as using telephonic verification or other approaches using data sources maintained by an MA organization or using publicly available data sets, that MA organizations may use for estimating accuracy scores”
The new paragraph requires the Secretary to specify the verification methods plans may use, such as telephone checks or approaches using plan data or public data sets, and for each method to specify a methodology for estimating the score. Each methodology must take into account the administrative burden on plans and providers and the relative importance of particular directory information to an enrollee's ability to get care.
What the document actually says
“The Secretary shall specify plan verification methods, such as using telephonic verification or other approaches using data sources maintained by an MA organization or using publicly available data sets, that MA organizations may use for estimating accuracy scores”
That sentence, in plain words
The health chief must name the ways a plan may check its list. A phone call is one way. Using data the plan holds is another.
What this is about
If each plan checked its own way, the scores could not be set side by side. Set methods make them fit together.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6220 in the PDF
What the document says
“Beginning with plan years beginning on or after January 1, 2029, the Secretary shall post accuracy scores (as reported under subparagraph (A)(ii)), in a machine readable file, on an internet website maintained by the Centers for Medicare & Medicaid Services.''.”
The new paragraph lets the Secretary waive its requirements for a specified MA plan with low enrollment, as the Secretary defines that. From plan years beginning on or after January 1, 2029, the Secretary must post the accuracy scores in a machine readable file on a website of the Centers for Medicare and Medicaid Services.
What the document actually says
“Beginning with plan years beginning on or after January 1, 2029, the Secretary shall post accuracy scores (as reported under subparagraph (A)(ii)), in a machine readable file, on an internet website maintained by the Centers for Medicare & Medicaid Services.''.”
That sentence, in plain words
From plan year 2029 the health chief must post the scores online. They must be in a form a computer can read.
What this is about
A plan with few people signed up may be let off. For the rest, the scores go public. Anyone can compare one plan with another.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Medicare Advantage organizationsHow: statuteSec. 6220 in the PDF
What the document says
“``(F) Provider directory.--Beginning with plan years beginning on or after January 1, 2029, in the case of a specified MA plan (as defined in section 1852(c)(3)(C)), the accuracy score of the plan's provider directory (as reported under section 1857(e)(6)(A)(ii)) listed prominently on the plan's provider directory.''.”
Section 6220 adds a new subparagraph (F) to section 1851(d)(4) of the Social Security Act. From plan years beginning on or after January 1, 2029, the accuracy score of a specified MA plan's provider directory must be listed prominently on that directory.
What the document actually says
“``(F) Provider directory.--Beginning with plan years beginning on or after January 1, 2029, in the case of a specified MA plan (as defined in section 1852(c)(3)(C)), the accuracy score of the plan's provider directory (as reported under section 1857(e)(6)(A)(ii)) listed prominently on the plan's provider directory.''.”
That sentence, in plain words
From plan year 2029 the score must sit on the doctor list itself. It must be easy to see.
What this is about
A score buried on an agency website helps few people. On the list itself, the reader sees it while using the list.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Centers for Medicare & Medicaid ServicesHow: statuteSec. 6220 in the PDF
What the document says
“there is appropriated to the Centers for Medicare & Medicaid Services Program Management Account, out of any money in the Treasury not otherwise appropriated, $4,000,000 for fiscal year 2026, to remain available until expended, to carry out the amendments made by this paragraph.”
Subparagraph (C) appropriates $4,000,000 to the Centers for Medicare and Medicaid Services Program Management Account for fiscal year 2026, in addition to amounts otherwise available, to remain available until expended, to carry out the accuracy analysis amendments.
What the document actually says
“there is appropriated to the Centers for Medicare & Medicaid Services Program Management Account, out of any money in the Treasury not otherwise appropriated, $4,000,000 for fiscal year 2026, to remain available until expended, to carry out the amendments made by this paragraph.”
That sentence, in plain words
Four million dollars goes to one account for 2026. It may be held until it is spent. It pays for the work of this part.
What this is about
Setting up the score system takes work at the agency. This money pays for that. Funds that stay available do not lapse at year end.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Comptroller General of the United StatesHow: statuteSec. 6220 in the PDF
What the document says
“Not later than January 15, 2033, the Comptroller General shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.”
Paragraph (3) of subsection (b) requires the Comptroller General to study how the amendments are put into practice, covering so far as data allow the use of the cost sharing protection, trends in accuracy scores overall and among mental health and substance use disorder providers, provider response rates by verification method, and administrative costs to providers and plans. The report is due to Congress by January 15, 2033.
What the document actually says
“Not later than January 15, 2033, the Comptroller General shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.”
That sentence, in plain words
By January 15, 2033 a watchdog office must send Congress a report on the study. It must add what it thinks Congress or the agency should do.
What this is about
A rule can work on paper and fail in practice. The study looks at what really happened. It comes years after the rules start.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6220 in the PDF
What the document says
“Not later than 6 months after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this subsection as the ``Secretary'') shall hold a public meeting to receive input on approaches for maintaining accurate provider directories for Medicare Advantage plans”
Subsection (c) of section 6220 requires the Secretary to hold a public meeting within six months of enactment on approaches to keeping provider directories accurate, including ways to reduce administrative burden such as data standardization. Participants must include representatives of the Centers for Medicare and Medicaid Services and of the Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology, and so far as practicable health care providers, technology companies, health insurers and patient advocates.
What the document actually says
“Not later than 6 months after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this subsection as the ``Secretary'') shall hold a public meeting to receive input on approaches for maintaining accurate provider directories for Medicare Advantage plans”
That sentence, in plain words
Within six months the health chief must hold a public meeting. It is to hear ideas on how to keep these doctor lists right.
What this is about
The meeting is open to anyone. Doctors, tech firms, insurers and patient groups are to be there. What they say shapes the guidance that follows.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6220 in the PDF
What the document says
“Not later than 18 months after the date of enactment of this Act, the Secretary shall issue guidance to Medicare Advantage organizations offering Medicare Advantage plans under part C of title XVIII of the Social Security Act”
Subsection (c) requires the Secretary to issue guidance to Medicare Advantage organizations within 18 months on keeping provider directories accurate, taking into account what was said at the stakeholder meeting. It may cover best practices, useful data sets and sources, approaches using plan and public data, and information useful to beneficiaries choosing a plan. Within 12 months the Secretary must also issue guidance to part B providers and suppliers on when to update the National Plan and Provider Enumeration System or a successor system.
What the document actually says
“Not later than 18 months after the date of enactment of this Act, the Secretary shall issue guidance to Medicare Advantage organizations offering Medicare Advantage plans under part C of title XVIII of the Social Security Act”
That sentence, in plain words
Within 18 months the health chief must give the plans guidance. It goes to the private plans that stand in for the public one.
What this is about
Guidance is advice, not a rule. A second piece goes to doctors within 12 months. It tells them when to update their own record.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The main things the section does: require an accurate public directory with verification, flagging and removal deadlines, define provider directory information and specified MA plan, cap cost sharing where an enrollee relied on a wrong listing, require three notifications, require an annual accuracy analysis and report with a score, provide for a waiver and for public posting, appropriate funding, require a GAO study and report, and require a stakeholder meeting and three pieces of guidance.
The items the directory must carry and the guidance may include, listed one by one. Both are recorded in summary.
The section amends the Social Security Act, which is not indexed here, so what Medicare Advantage plans otherwise must do is not recorded on this site.
