S. 2793 — Ensuring Access to Essential Providers Act of 2025

This section requires Medicare Advantage (MA) organizations to meet an essential community provider (ECP) standard—newly added to the provider network requirements under SSA section 1852(d)(1)—by including in each plan's network (1) an amount (as determined by the Secretary) of available ECPs and offering contracts to all such ECPs in the service area; (2) a sufficient number and geographic distribution of available ECPs to ensure reasonable and timely access for low-income individuals, rural residents, and those in health professional shortage areas; and (3) payments to Federally Qualified Health Centers (FQHCs) consistent with SSA section 1857(e)(3). (As background, MA plans, which serve as a private alternative to traditional Medicare Part B and cover over half of Medicare beneficiaries, must maintain adequate provider networks for CMS approval.) If an MA plan does not meet the ECP standard, the organization must submit with its bid under SSA section 1854(a) an explanation, a narrative justifying adequate service levels for low-income and shortage-area enrollees, and plans to meet the standard next year; insufficient justification results in CMS non-approval of the plan. ECPs are defined to include FQHCs, Ryan White HIV/AIDS Program facilities, Indian Health Service providers, disproportionate share hospitals and other specified hospitals, mental health and substance use facilities, certain public health clinics, and others serving predominantly low-income or medically underserved individuals, as determined by the Secretary.