REAL Health Providers Act: Proposed MA Plan Provider Directory Requirements

It can be difficult for health plans to keep track of the compliance requirements around maintaining accurate provider directories. Provider data accuracy requirements are constantly evolving and health plans need to verify that their directories don’t have outdated information. Kyruus Health monitors legislation that may impact health plans with respect to our care access platform, and the recently proposed REAL Health Providers Act falls into that category. 

Kyruus Health’s Vice President of Regulatory, Sydney Edwards, breaks down the bipartisan legislative proposal formally called the Requiring Enhanced and Accurate Lists (REAL) of Health Providers Act. She summarizes the provider directory requirements that Medicare Advantage (MA) plans would need to meet, and explains how meeting them helps avoid ghost networks—illustrating the importance of provider data accuracy to health plans and their members. For a transcript of the video, continue reading.

Requiring Enhanced and Accurate Lists (REAL) Health Providers Act

We’ve had a lot of questions about the proposed bipartisan legislation called the REAL Health Providers Act. It was introduced to ensure Medicare Advantage (MA) plans maintain accurate provider directories and protect consumers from unexpected health care costs. I’m going to review the key provisions so you have an understanding of how it might impact your business.

While these requirements are specific to Medicare Advantage plans, the underlying problem of inaccurate provider data is universal. Imagine a member’s frustration when searching for care, only to find the provider has outdated contact information, or is not accepting new patients or even worse, is no longer in-network. These “ghost networks” occur in directories where providers seem readily available, but in reality are not. This pervasive issue is what the REAL Act attempts to address.

Key Requirements of the REAL Health Providers Act

If passed, beginning plan year (PY) 2026, the REAL act would require: 

• Removal of providers no longer in-network within 5 business days

  • From both online and print directories after determining the provider is no longer participating in the Medicare Advantage network.

• Cost sharing protections for enrollees 

  • For services resulting from incorrect provider network information – so members don’t get stuck with out-of-network charges due to bad information.
  • As well as member notification of cost sharing requirements – during enrollment, within EOBs as well as within the directory itself – creating transparency for members.

• Provider directory verification every 90 days

  • Also called attestation, to ensure provider information is correct. 
  • For unverified providers, the ability to indicate in the directory that information displayed may not be up-to-date.

• Accuracy reporting requirements for online & printed provider directories 

  • An accuracy score will be published annually on CMS’s website in MRF format. More guidance is expected to come on how to measure and report the score.
  • CMS will pay particular attention to data accuracy for mental health and substance use disorder providers.

Provider Data Accuracy and Care Access

Provider data accuracy is at the core of our mission to connect people to the right care. Strengthening requirements for Medicare Advantage plans to maintain and update accurate information is important to building member trust, maintaining satisfaction, and streamlining access to care—particularly for specialties with historically high inaccuracy rates.

Reach out to us for more information on how our solutions support the provider data accuracy requirements of the REAL Health Providers Act.

As part of our commitment to our clients, we regularly monitor proposed and passed regulatory and compliance legislation that might impact their business. Not only does this allow us to help clients stay informed and navigate upcoming changes, but it becomes a contributing factor to our evaluation of enhancements to our product roadmap and solutions.

The most recent rulemaking became effective January 2024, when CMS added new print and online provider directory requirements applicable to Medicare Advantage (MA) plans. As new healthcare mandates tend to do, these changes impose additional regulatory burden on MA plan issuers. CMS has even acknowledged that the adoption of these new requirements may result in “increased provider burden and abrasion.” On the bright side, our internal review determined that Kyruus Health’s current solutions broadly support the functionality to meet the requirements.

In general, the ruling adds requirements that resonate with the core of Kyruus Healths’ mission to connect people to the right care:

• Supporting equitable patient access
• Improved continuity of care
• Usability of provider directories

More specifically, the provider directory requirements include a new “linguistic capabilities” attribute, broadens the search requirements across all elements, strengthens translation requirements, and mandates notifications when a provider leaves a network. While CMS rulemaking can sometimes be difficult to interpret and implement, we believe that it is our responsibility to help bridge disparities and improve patient outcomes as we strive to meet the needs of a growing and diversified population.

Our recent survey data highlights the importance of providing members with the best possible digital experiences:

• Of people who research their care option online, 58% of consumers first search for a provider on their health plan website—more than for any other online source
• Out of 79% of consumers who use their insurer’s healthcare transparency tools, 88% agree that the tools helped them make more informed decisions

Kyruus Health’s care access platform powers the provider directories for many of the nation’s leading healthcare organizations, and we don’t take that privilege lightly. We are committed to our clients and their members, helping people find the care they need by providing an accurate and transparent directory for consumers, while at the same time meeting any healthcare compliance requirements.

Reach out to learn more about how we can help your organization transform care access and delivery.