Everything You Need to Navigate July 1st Provider Directory Changes

On July 1, 2025, new federal regulations under Section 5123 of the Consolidated Appropriations Act, 2023 (CAA, 2023) will require Medicaid and Children’s Health Insurance Program (CHIP) provider directories to be more accurate, accessible, and frequently updated.  

These Centers for Medicare & Medicaid Services (CMS) regulations bring Medicaid and CHIP in line with Medicare and commercial plans, and noncompliance could lead to corrective actions or reduced federal funding.

Here’s what’s changing—and how Medicaid and CHIP health plans can prepare.

Who Is Impacted by These New Requirements?

The new provider directory requirements outlined in the Consolidated Appropriations Act, 2023, specifically impact Medicaid and CHIP. These rules apply to:

• Medicaid Fee-for-Service (FFS)

• Medicaid Managed Care Organizations (MCOs)

• CHIP Fee-for-Service (FFS)

• CHIP Managed Care Entities

Who Is Not Directly Impacted?

• Medicare Plans – Medicare directories are not included in these mandates, though they are subject to separate CMS regulations.

• Commercial Health Plans – Employer-sponsored insurance, ACA marketplace plans, and other private health plans are not bound by these specific requirements, but may have similar state-level regulations.

Similar requirements have been in place for years in Medicare Advantage and ACA marketplace plans—especially in terms of directory accuracy and quarterly updates—though they are governed by different regulations such as the No Surprises Act and Interoperability Rule.

Key Updates Health Plans Need to Know

✅ Increased Update Frequency

• New Requirement: Provider directories must be updated at least quarterly (previously annual updates).

• Impact: Health plans must establish processes for more frequent and timely updates to avoid outdated or misleading provider information.

✅ Expanded Data Requirements

Health plans must now include additional data elements in provider directories. Patients should be able to search for:

• Telehealth Availability – Whether a provider offers covered services remotely via telehealth.

• Physical Disability Accommodations – Accessibility details for offices, exam rooms, and equipment.

• Linguistic and Cultural Competency – Including available spoken languages, American Sign Language (ASL), and cultural expertise.

• Internet Presence – Provider’s website, if applicable.

• Provider Availability – Whether the provider is accepting new Medicaid or CHIP patients.

• Expanded Provider Types – Inclusion of mental health services, substance use disorder services, and long-term care providers.

✅ Provider Directory API Mandate

• New Requirement: Medicaid and CHIP directories must be publicly accessible via an HL7 FHIR-compliant API.

• Impact: Plans must ensure technical infrastructure is in place for real-time provider data updates through API integration.

✅ Compliance Deadline and Non-Compliance Measures

• Health plans must comply by July 1, 2025.  

• CMS will issue corrective action plans (CAPs) for non-compliance.

• Penalties: Non-compliant systems may lose federal funding participation (FFP), dropping from 75% to 50% reimbursement for directory-related costs.

• States can request federal funding (FFP) at 90/10 for system improvements if they submit an Advanced Planning Document (APD).

10-Step Action Plan for Health Plans

1. Assess Current Directory Systems

• Conduct a gap analysis between existing provider directory capabilities and the new requirements.

• Identify missing data fields (telehealth, disability accommodations, cultural competencies).

2. Engage IT Teams & Vendors

• Develop a roadmap for integrating HL7 FHIR API for interoperability.

• Identify automation opportunities for real-time updates.

3. Establish Internal Compliance Task Force

• Assign a compliance lead to oversee updates and reporting.

• Coordinate with provider relations teams to communicate new mandate and impact to providers

4. Pilot & Test Quarterly Update Process

• Implement and test automated provider data updates to meet the quarterly update requirement.

• Validate data accuracy to avoid compliance risks.

5. Enhance Data Collection Methods

• Partner with providers to ensure all required fields (accessibility, language services) are properly documented and received

• Implement quality control processes to monitor provider data integrity.

6. Submit Funding Requests (If Needed)

• Apply for enhanced federal financial participation (FFP) at 90/10 to cover development costs.

7. Full Implementation & Compliance Audit

• Conduct a final audit to confirm compliance with quarterly update requirements.

• Verify HL7 FHIR API functionality and ensure public accessibility.

8. Staff Training

• Train internal teams on new provider directory processes.

9. Provider Engagement

• Conduct outreach to providers to ensure they update their directory information regularly.

10. Prepare for CMS Review & Reporting

• Have a corrective action plan (CAP) template ready in case of compliance challenges.

• Maintain documentation of updates, training efforts, and data accuracy reports.

How Leap Orbit is Supporting Customers Through Regulatory Changes

At Leap Orbit, we recognize that regulatory updates can be complex and resource-intensive for health plans. That’s why we are committed to being a reliable partner in compliance—ensuring that you meet new CMS provider directory requirements without disrupting your operations.

As part of this commitment, we are proactively working with all CareFinDr customers to ensure a smooth transition ahead of the July 1, 2025, deadline.  

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Here’s what we’re doing:

Automated Compliance Updates

Quarterly Directory Updates: Provider directories must now be refreshed at least every quarter instead of annually.  

• CareFinDr will automatically reflect the most recent update date, requiring no additional action on your part.

Expanded Data Collection: New requirements include fields for telehealth services, physical disability accommodations, and linguistic capabilities.  

• We are already reviewing your existing files and will be reaching out with clear next steps to help you collect and integrate this data seamlessly.

HL7 FHIR API Readiness

Medicaid and CHIP Program Compliance: Directories must support mandatory API implementation using HL7 FHIR standards.  

• We are reviewing your data and will provide tailored guidance on the next steps to ensure compliance.

Ongoing Enhancements to CareFinDr

• We are continuously improving CareFinDr and our full suite of provider data solutions to keep pace with evolving regulations. Our goal is to minimize compliance burden, streamline data management, and empower your team to focus on delivering care.

Conclusion

The July 1, 2025 provider directory mandate represents a major regulatory shift that will require significant operational and technical updates from health plans. Proactively addressing these compliance requirements will help avoid penalties, improve provider data accuracy, and enhance the patient experience.

By following this action plan, health plans can navigate the changes efficiently while ensuring regulatory compliance.