Sponsors (9)
The bill improves financial protections and directory transparency for Medicare Advantage enrollees but does so at the cost of added administrative burden, enforcement risk, and potential privacy/security concerns that could raise plan costs or affect providers.
Medicare Advantage enrollees will pay lower out-of-pocket cost sharing when a nonparticipating provider listed in a plan directory furnishes covered care — cost sharing limited to the lesser in‑network amount beginning in 2028.
Medicare Advantage enrollees (including people with chronic conditions) will have better ability to find appropriate clinicians because plans must maintain more up-to-date directory data (languages, telehealth availability, accepting new patients, etc.).
Medicare Advantage plans and participating providers must incur additional administrative work and verification/reporting costs (90‑day verification, accuracy analyses, mandatory reporting), which will likely raise plan operating costs and could be passed to enrollees via higher premiums or reduced benefits.
Plans face new enforcement exposure (civil monetary penalties or corrective actions) for noncompliance, which could reduce plan offerings or encourage more conservative network practices to avoid sanctions.
Hospitals, health systems, and individual clinicians face increased risk that publicly available, machine‑readable provider contact and practice data could be misused or raise privacy/security concerns if data stewardship is inadequate.
Based on analysis of 2 sections of legislative text.
Requires specified Medicare Advantage plans to verify and update provider directories, add identified data elements, flag/remove unverifiable listings, and extend enrollee cost-sharing protections when a listed provider is not participating (effective plan year 2028).
Official title: To amend title XVIII of the Social Security Act to establish provider directory requirements, and to provide accountability for provider directory accuracy, under Medicare Advantage.
Introduced September 10, 2025 by James Varni Panetta · Last progress September 10, 2025
Requires Medicare Advantage plans that rely on provider networks (and certain private fee-for-service plans that meet access-by-contract standards) to keep accurate, public provider directories, verify and update listings at least every 90 days (with stricter timing for facilities), flag unverifiable entries, and remove nonparticipating providers quickly. Starts for plan year 2028 and adds Medicare Advantage enrollee cost-sharing protections and notice requirements when an enrollee receives care from a provider who was listed in the plan directory but is not actually participating.