← Back to Bill Feed
FederalIn Committee
Medicare Advantage Improvement Act of 2026
Introduced Apr 20, 2026 · Last action Apr 27, 2026 — Sponsor introductory remarks on measure. (CR H3095)
Track this bill
Save bills and get alerts when status changes.
Sign in to saved bills.
Summary
This legislation is called the Medicare Advantage Improvement Act of 2026. Sponsor introductory remarks on measure. (CR H3095).
Full bill text
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8375 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 8375
To amend title XVIII of the Social Security Act to provide for certain
reforms under the Medicare Advantage program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 20, 2026
Mr. Joyce of Pennsylvania (for himself, Ms. Schrier, Mr. Murphy, Mr.
Panetta, Mrs. Miller-Meeks, Mr. Bera, and Ms. Van Duyne) introduced the
following bill; which was referred to the Committee on Ways and Means,
and in addition to the Committee on Energy and Commerce, for a period
to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to provide for certain
reforms under the Medicare Advantage program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Advantage Improvement Act
of 2026''.
SEC. 2. IMPROVING ACCESS TO TIMELY CARE FOR ENROLLEES OF MEDICARE
ADVANTAGE PLANS.
(a) Reducing Timeframes for Medicare Advantage Organizations To
Respond to Certain Authorization Requests.--
(1) Standard organization determinations.--Section
1852(g)(1) of the Social Security Act (42 U.S.C. 1395w-
22(g)(1)) is amended--
(A) in subparagraph (A), in the second sentence, by
inserting ``subparagraph (C) and'' after ``Subject
to'';
(B) in subparagraph (B), by striking ``Such a
determination'' and inserting ``A determination
described in subparagraph (A) or (C)''; and
(C) by adding at the end the following new
subparagraph:
``(C) Required timeframes for responses to certain
authorization requests.--
``(i) In general.--Subject to clause (ii)
and paragraph (3)(B)(iii), the procedure
established pursuant to subparagraph (A) by a
Medicare Advantage organization offering an MA
plan shall provide that in the case of a
request made on or after January 1, 2028, for a
specified authorization (as defined in clause
(iii)) with respect to an individual enrolled
under such plan, the Medicare Advantage
organization must notify the individual (and
the provider of services or supplier involved,
as appropriate) of the determination regarding
such request as expeditiously as the health
condition of the individual requires, but,
subject to clause (iv), not later than 72 hours
after receipt of the request.
``(ii) Extensions.--Subject to clause (iv),
a Medicare Advantage organization offering an
MA plan may extend the deadline applied under
clause (i) or the deadline applied under
paragraph (3)(B)(iii)(II), as applicable, with
respect to a determination regarding a
specified request for an individual enrolled
under the MA plan, by up to 7 calendar days
if--
``(I) the individual requests the
extension;
``(II) the extension is needed for
purposes of obtaining additional
relevant medical evidence from a
provider of services or supplier that
does not have a contract with the MA
organization to furnish items and
services to individuals enrolled under
the MA plan; or
``(III) the extension is in the
individual's interest and is justified
by reason of extraordinary, exigent, or
other nonroutine circumstances that are
not within the reasonable control of
the MA organization (as determined by
the Secretary).
``(iii) Specified authorization defined.--
For purposes of this part, the term `specified
authorization'--
``(I) means, with respect to an
individual enrolled under an MA plan
offered by a Medicare Advantage
organization, an authorization of
coverage or payment for an item or
service through--
``(aa) a prior
authorization or preservice
determination of coverage or
payment; or
``(bb) a concurrent
determination made while the
individual is receiving the
relevant item or service; and
``(II) includes an authorization
for a transfer of the individual
between hospitals or between a hospital
and post-acute care facility.
``(iv) Secretarial authority.--With respect
to requests for a specified authorization made
on or after January 1, 2030, in carrying out
clause (i) and (ii) and paragraph
(3)(B)(iii)(II), the Secretary may specify
through notice and comment rulemaking a
deadline other than the deadline specified in
the relevant clause or paragraph.''.
(2) Expedited organization determinations.--Section
1852(g)(3)(B)(iii) of the Social Security Act (42 U.S.C. 1395w-
22(g)(3)(B)(iii)) is amended--
(A) by striking ``Timely response.--In cases
described'' and inserting: ``Timely reponse.--
``(I) In general.--Subject to
subclause (II), in cases described'';
and
(B) by adding at the end the following new
subclause:
``(II) Reducing expedited
timeframes for responses to certain
authorization requests.--Subject to
paragraph (1)(C)(ii), in cases
described in clauses (i) and (ii) that
are related to an expedited
determination for a specified
authorization (as defined in paragraph
(1)(C)(iii)) for which a request is
submitted on or after January 1, 2028,
the Medicare Advantage organization
shall notify the enrollee (and the
physician involved, as appropriate) of
the determination under time
limitations established by the
Secretary. Subject to paragraph
(1)(C)(iv), such notification shall be
made not later than 24 hours after the
receipt of the request for the
determination (or receipt of the
information necessary to make the
determination).''.
(3) Improved transparency of certain prior authorization
information on the ma plan level.--Beginning with plan years
beginning on or after January 1, 2028, in carrying out the
provisions of section 422.122(c) of title 42, Code of Federal
Regulations (or any successor regulation), the Secretary of
Health and Human Services shall--
(A) require Medicare Advantage organizations to
report prior authorization data described in such
section on the plan level and on the Medicare Advantage
organization parent level in addition to the contract
level;
(B) require Medicare Advantage organizations to
report prior authorization data described in such
section in a manner that allows comparison of such data
based on provider and service category; and
(C) in addition to making such data publicly
available, as described in such section, make such data
available in a downloadable format that is accessible
for research purposes and oversight and enforcement
activities of the Secretary.
(b) Real-Time Authorization Decisions for Certain Identified
Services.--Section 1852(g)(1) of the Social Security Act (42 U.S.C.
1395w-22(g)(1)), as amended by subsection (a), is further amended--
(1) in subparagraph (A), in the second sentence, by
striking ``subparagraph (C) and'' and inserting ``subparagraphs
(C) and (D) and'';
(2) in subparagraph (B), by striking ``A determination
described in subparagraph (A) or (C)'' and inserting ``A
determination described in subparagraph (A), (C), or (D)'';
(3) in subparagraph (C)(i), by striking ``Subject to clause
(ii)'' and inserting ``Subject to clause (ii), subparagraph
(D),''; and
(4) by adding at the end the following new subparagraph:
``(D) Real-time authorization decisions for
identified services.--
``(i) In general.--The procedure
established pursuant to subparagraph (A) shall
require that the Medicare Advantage
organization has in place a mechanism and
process through which, beginning January 1,
2028, the organization provides a real-time
determination, in accordance with this
subparagraph, in response to any request for a
specified authorization (as defined in
subparagraph (C)(iii)) that is--
``(I) made with respect to an item
or service identified on the most
recent list published pursuant to
clause (iii); and
``(II) submitted through certified
EHR technology (as defined in section
1848(o)(4)).
``(ii) Requirements for real-time mechanism
and process.--The mechanism and process
required under clause (i) shall--
``(I) include real-time tools
capable of providing immediate
automated approvals;
``(II) provide for the integration
of such tools in a manner that is
interoperable with certified EHR
technology (as so defined) used by
providers of services and suppliers;
and
``(III) enable immediate
notification to the provider of
services or supplier, as applicable, of
determinations, including, in the case
of a denial, notification of any
additional documentation needed.
``(iii) Annual publication of list of
identified services requiring real-time
authorization support.--For purposes of this
subparagraph, for each plan year beginning on
or after January 1, 2028, the Secretary shall
annually establish through notice and comment
rulemaking a list identifying the following
items and services:
``(I) Items and services for which,
with respect to the previous plan year,
at least 90 percent of requests for a
specified authorization were approved
across all Medicare Advantage
organizations.
``(II) Items and services that are
clinically low-risk and routine, as
defined by the Secretary through notice
and comment rulemaking.
``(III) Items and services that the
Secretary identifies, according to
standards specified by the Secretary
through notice and comment rulemaking,
as representative of significant
service volume and administrative
burden for acquiring such a specified
authorization.
``(iv) Improving transparency.--
``(I) Quarterly mao reports to
cms.--Beginning January 1, 2028, and
quarterly thereafter, each Medicare
Advantage organization offering an MA
plan shall submit to the Secretary (in
a form and manner specified by the
Secretary) information (presented by
provider and service type) regarding
real-time determinations made by the
organization during the previous
quarter pursuant to this subparagraph,
including information on--
``(aa) the number of real-
time determinations made during
the quarter, and the percentage
of all determinations made
during the quarter with respect
to an item or service
identified on the most recent
list published pursuant to
clause (iii) that were real-
time determinations;
``(bb) the number and
percentage of real-time
determinations made during such
quarter that were approved;
``(cc) the number and
percentage of such
determinations that were
denied;
``(dd) the number and
percentage of such denied
determinations that were
appealed;
``(ee) the number and
percentage of such appealed
determinations that were
overturned; and
``(ff) the number and
percentage of provider
complaints regarding the
mechanism and process
implemented by the Medicare
Advantage organization pursuant
to this subparagraph.
The information submitted pursuant to
the previous sentence shall include
such information and be provided in
such a manner to enable comparison and
analysis of such information on the
Medicare Advantage organization level,
Medicare Advantage parent organization
level, and MA plan level.
``(II) Public availability of
information.--The Secretary shall make
information collected under subclause
(I) publicly available on the internet
website of the Centers for Medicare &
Medicaid Services.''.
(c) Prohibiting Certain Authorization Processes for Certain
Clinically Necessary Changes and Extensions.--Section 1852(d) of the
Social Security Act (42 U.S.C. 1395w-22(d)) is amended by adding at the
end the following new paragraph:
``(7) Prohibition on requiring certain authorizations.--
Beginning January 1, 2028, in the case that a Medicare
Advantage organization offering an MA plan provides approval
through a specified authorization (as defined in subsection
(g)(1)(C)(iii)) for an item or service to be furnished to an
individual enrolled in the plan by a provider of services or
supplier, if during the course of furnishing such approved item
or service the provider of services or supplier determines that
a modification, extension, or adjustment to such item or
service is clinically necessary, the Medicare Advantage
organization may not require a specified authorization (as
defined in subsection (g)(1)(C)(iii)) to be requested with
respect to such item or service as so modified, extended, or
adjusted. Application of the previous sentence shall not limit
the authority of the Medicare Advantage organization to require
documentation or post-service notification of any such
modification, extension, or adjustment.''.
(d) Improvements to the Reconsiderations Process.--Section 1852(g)
of the Social Security Act (42 U.S.C. 1395w-22(g)) is amended--
(1) in paragraph (2)--
(A) in subparagraph (A), by inserting ``(or, with
respect to determinations made on or after January 1,
2028, not later than 14 days)'' after ``60 days''; and
(B) by adding at the end the following new
subparagraph:
``(C) Reconsiderations affirming denials of
coverage.--If a reconsideration affirms (in whole or in
part) a denial of coverage (including an adverse
organization determination under section 422.590 of
title 42, Code of Federal Regulations, or any successor
regulation) made on or after January 1, 2028, with
respect to an individual enrolled in an MA plan offered
by a Medicare Advantage organization, the Medicare
Advantage organization shall submit to the independent,
outside entity with a contract under paragraph (4) the
case file and written explanation of the decision as
expeditiously as the individual's health condition
requires, but not later than 14 days after the date the
Medicare Advantage organization received the request
for the reconsideration.''; and
(2) in paragraph (4)--
(A) by striking ``coverage denials.--The Secretary
shall contract with'' and inserting: ``coverage
denials.--
``(A) In general.--The Secretary shall contract
with''; and
(B) by adding at the end the following new
subparagraphs:
``(B) Requirements.--In reviewing and resolving
pursuant to subparagraph (A) a reconsideration of a
determination of a Medicare Advantage organization made
on or after January 1, 2028, with respect to an
individual enrolled in an MA plan offered by the
organization, the independent, outside entity shall
comply with each of the following requirements:
``(i) Notice and opportunity to provide
supporting documentation.--The entity shall--
``(I) not later than 3 days after
the date of receipt of the relevant
case file from the Medicare Advantage
organization, submit to the individual,
the representative of the individual
(if applicable), and the provider of
services or supplier furnishing (or
ordering) the item or service that is
the subject of the determination, a
notification regarding the opportunity
to submit documentation, including
medical records, regarding medical
necessity; and
``(II) provide a period of 7 days
from the date of receipt of such
notification for submission of any such
documentation.
``(ii) Decision timeframe.--After reviewing
and considering all supporting documentation
received before the end of the 7-day period
described in clause (i)(II), the entity shall
issue its decision with respect to such
reconsideration as expeditiously as the
individual's health condition requires, but by
not later than the applicable number of days
specified in subparagraph (C) after the last
day of the 7-day period described in clause
(i)(II).
``(C) Applicable number of days.--For purposes of
subparagraph (B)(ii), the applicable number of days
specified in this subparagraph is--
``(i) 14 days, in the case of a request
(other than with respect to an expedited
reconsideration under paragraph (3)) for
coverage of an item or service that is not a
drug for which payment may be made under part
B;
``(ii) 7 days, in the case of a request
(other than with respect to an expedited
reconsideration under paragraph (3)) for
coverage of a drug for which payment may be
made under part B;
``(iii) 30 days, in the case of a request
(other than with respect to an expedited
reconsideration under paragraph (3)) for
payment of an item or service; and
``(iv) 24 hours, in the case of a request
with respect to an expedited reconsideration
under paragraph (3).''.
SEC. 3. ENSURING APPROPRIATE OVERSIGHT OF MEDICARE ADVANTAGE PLANS.
(a) MAO Compliance Scoring and Accountability Program.--Section
1853 of the Social Security Act (42 U.S.C. 1395w-23) is amended by
adding at the end the following new subsection:
``(p) Compliance Scoring and Enforcement.--
``(1) Payment reductions for maos in noncompliance with
certain ma program requirements.--
``(A) In general.--In the case of a Medicare
Advantage organization with a contract under this part
that the Secretary determines, in accordance with this
subsection, to be within a compliance tier specified in
subparagraph (B) for a performance period with respect
to a plan year beginning on or after January 1, 2028,
the Secretary shall reduce the total of the monthly
payments made for the plan year under section
1853(a)(1) to the Medicare Advantage organization with
respect to each Medicare Advantage plan offered by such
organization by the applicable percent specified under
subparagraph (B) with respect to the compliance tier.
``(B) Applicable percent specified.--For purposes
of subparagraph (A), the applicable percent specified
under this subparagraph is as follows:
``(i) With respect to the compliance tier
described in paragraph (5)(B), 1.0 percent.
``(ii) With respect to the compliance tier
described in paragraph (5)(C), 1.5 percent.
``(iii) With respect to the compliance tier
described in paragraph (5)(D), 2.0 percent.
``(C) Performance period.--For purposes of this
subsection, the Secretary shall establish a performance
period (or periods) for each plan year beginning on or
after January 1, 2028. Such performance period (or
periods) shall begin and end prior to the beginning of
the plan year and be as close as possible to such plan
year. In this subsection, such performance period (or
periods) for a plan year shall be referred to as the
performance period with respect to the plan year.
``(2) Establishment of compliance scoring and
accountability program.--For purposes of this subsection, the
Secretary shall establish a Medicare Advantage organization
compliance scoring and accountability program (referred to
under this subsection as the `MAO Compliance Program') under
which, for each Medicare Advantage organization with a contract
under this part and each performance period with respect to a
plan year beginning on or after January 1, 2028, the
Secretary--
``(A) using the method established under paragraph
(3)(A), shall assess the extent to which the Medicare
Advantage organization is in compliance with
requirements under this part applicable to each
compliance category specified under paragraph (3)(B);
``(B) based on such assessments for each such
compliance category, shall assign a total compliance
score to the Medicare Advantage organization, in
accordance with paragraph (4); and
``(C) based on such total compliance score, shall
assign the Medicare Advantage organization to a
compliance tier described in paragraph (5).
``(3) Assessment method.--
``(A) In general.--Under the MAO Compliance
Program, the Secretary shall establish through notice
and comment rulemaking a method to assess, at the plan
level, the extent to which each Medicare Advantage
organization offering a Medicare Advantage plan is in
compliance with requirements under this part applicable
to each compliance category specified in subparagraph
(B). Such method shall include the use of audit
mechanisms, reporting requirements, performance
measures established or identified by the Secretary
(such as applicable measures under the MA Program
Compliance and Coverage Protection Domain described in
section 1853(o)(8)), and such other methods as
specified by the Secretary.
``(B) Compliance categories.--
``(i) In general.--Subject to clause (ii),
under the MAO Compliance Program, each of the
following shall be a compliance category:
``(I) Compliance with timely and
real-time specified authorization
decision-making requirements, including
compliance with section 1852(d)(7) and
paragraphs (1)(C), (1)(D), and
(3)(B)(iii)(II) of section 1852(g).
``(II) Compliance with coverage
criteria standards, including the
requirements under section 1852(g)(7)
and section 1852(a)(2)(D).
``(III) Compliance with prompt
payment requirements, including
compliance with section 1857(f).
``(IV) Compliance with restrictions
regarding improper retroactive denials
and downgrades, including compliance
with section 1852(g)(6) and section
1857(e)(6).
``(V) Compliance with marketing,
enrollment, and beneficiary
communication requirements, including
subpart V of part 422 of title 42, Code
of Federal Regulations, or any
successor to such regulations.
``(VI) Compliance with other
requirements under this part, including
section 1852(g)(1)(E) and such other
requirements as specified by the
Secretary.
``(ii) Updates.--The Secretary may, through
notice and comment rulemaking, revise the
compliance categories described in clause (i),
including by specifying additional categories,
removing categories, and otherwise updating the
requirements that are included in any of such
compliance categories.
``(4) Scoring methodology.--Under the MAO Compliance
Program, the Secretary shall, through notice and comment
rulemaking, establish a methodology to assign a total
compliance score (using a scoring scale of 0 to 100) to each
Medicare Advantage organization for the performance period with
respect to a plan year. Such total compliance score shall be
based on the assessment under paragraph (3) of plan-level
compliance with respect to each compliance category described
in subparagraph (B) of such paragraph, with each such category
receiving equal weight (and, in the case of a Medicare
Advantage organization offering more than one plan during the
performance period, with each such assessment weighted by the
number of individuals enrolled under such plan during such
period).
``(5) Compliance tiers.--For each plan year beginning on or
after January 1, 2028, the Secretary shall, based on the total
compliance score assigned pursuant to paragraph (4) to a
Medicare Advantage organization for the performance period with
respect to such year, assign such Medicare Advantage
organization to one of the following compliance tiers, as
follows:
``(A) Compliance tier one, consisting of Medicare
Advantage organizations receiving a total score for the
performance period of at least 90.
``(B) Compliance tier two, consisting of Medicare
Advantage organizations receiving a total score for the
performance period of at least 75 but not more than 89.
``(C) Compliance tier three, consisting of Medicare
Advantage organizations receiving a total score for the
performance period of at least 60 but not more than 74.
``(D) Compliance tier four, consisting of Medicare
Advantage organizations receiving a total score for the
performance period of less than 60.
``(6) Review.--The Secretary shall establish a process
under which a Medicare Advantage organization may seek a review
of the total compliance score assigned to the organization
pursuant to paragraph (4) for a performance period.
``(7) Public disclosures.--
``(A) In general.--For each plan year beginning on
or after January 1, 2028, the Secretary shall make
available on a public website of the Centers for
Medicare & Medicaid Services and in an easily
understandable format, information regarding the
assessments under the MAO Compliance Program of
compliance during the performance period with respect
to the plan year by Medicare Advantage organizations,
on the plan level, with requirements applicable to each
compliance category specified in paragraph (3)(B). Such
information shall include the total compliance score
received by each Medicare Advantage organization
pursuant to paragraph (4) for the performance period.
``(B) Opportunity to review and submit
corrections.--The Secretary shall provide for an
opportunity for a Medicare Advantage organization to
review and submit corrections for the information to be
made available under subparagraph (A) with respect to
such organization prior to such information being made
public.''.
(b) Expanding the MA Star Ratings Program To Include an MA Program
Compliance and Coverage Protection Domain.--
(1) Data collection.--Section 1852(e)(3) of the Social
Security Act (1395w-22(e)(3)) is amended--
(A) in subparagraph (A)(i), in the first sentence
by inserting ``, including, for plan years beginning on
or after January 1, 2028, with respect to measures
under the MA Program Compliance and Coverage Protection
Domain described in section 1853(o)(8)'' after ``other
indices of quality''; and
(B) in subparagraph (B)(i), by inserting ``, and
other than the types of data authorized under
subparagraph (C) of section 1853(o)(8) for purposes of
the MA Program Compliance and Coverage Protection
Domain described in such section'' after ``as of
November 1, 2003''.
(2) Addition of ma program compliance and coverage
protection domain to ma star ratings system.--Section 1853(o)
of the Social Security Act (1395w-23(o)) is amended by adding
at the end the following new paragraph:
``(8) MA program compliance and coverage protection
domain.--
``(A) In general.--For plan years beginning on or
after January 1, 2028, in addition to any other domain
under the 5-star rating system under paragraph (4)(A)
used for determining star ratings of Medicare Advantage
plans, the Secretary shall include under such system an
MA Program Compliance and Coverage Protection Domain.
``(B) Measures.--Such domain shall include measures
to assess compliance of each Medicare Advantage plan
with each of the compliance categories specified in
section 1853(p)(3)(B).
``(C) Data.--For purposes of determining star
ratings with respect to measures under the MA Program
Compliance and Coverage Protection Domain, in addition
to sources of data otherwise collected under section
1852(e)(3), the Secretary may use data collected
pursuant to audits, complaint tracking systems, appeals
data, determinations made by independent review
entities, and such other sources as specified by the
Secretary.
``(D) Application of weighting.--In applying
section 422.166(e) of title 42, Code of Federal
Regulations, or a successor regulation, with respect to
the MA Program Compliance and Coverage Protection
Domain, the Secretary shall assign a weight to measures
included under such domain that is greater than the
weight assigned to measures included under any other
domain.''.
SEC. 4. GUARDRAILS ON RETROSPECTIVE CLAWBACKS.
(a) Application of Prompt Payment Requirements to All Claims for
Which Authorization Was Provided.--Section 1857(f) of the Social
Security Act (42 U.S.C. 1395w-27(f)) is amended--
(1) in paragraph (1)--
(A) in the header, by inserting ``for items and
services furnished by out-of-network providers of
services and suppliers'' after ``requirement''; and
(B) by striking ``A contract'' and inserting
``Subject to paragraph (2), a contract'';
(2) in paragraph (2), by striking ``in compliance with
paragraph (1)'' and inserting ``in compliance with paragraphs
(1) and (2)'';
(3) by redesignating paragraphs (2) and (3) as paragraphs
(3) and (4), respectively; and
(4) by inserting after paragraph (1) the following new
paragraph:
``(2) Requirement for items and services for which
authorization was provided.--
``(A) In general.--For contract years beginning on
or after January 1, 2028, a contract under this part
shall require a Medicare Advantage organization to
provide prompt payment (consistent with the provisions
of sections 1816(c)(2) and 1842(c)(2)) of qualifying
claims submitted for authorized items and services (as
defined in subparagraph (B)) furnished to enrollees
under the plan, except that in applying the provisions
of such sections--
``(i) references to `not less than 95
percent of all claims submitted' shall be
treated as references to `100 percent of all
claims submitted'; and
``(ii) every qualifying claim (as described
in subparagraph (C)) submitted for an
authorized item or service shall be deemed to
be a clean claim referred to in such sections.
``(B) Authorized item or service defined.--For
purposes of this paragraph, the term `authorized item
or service' means an item or service--
``(i) that is furnished by a provider of
service or supplier to an individual enrolled
in a Medicare Advantage plan offered by a
Medicare Advantage organization; and
``(ii) for which approval was provided by
the Medicare Advantage organization through a
specified authorization (as defined in section
1852(g)(1)(C)(iii)).
``(C) Qualifying claim described.--For purposes of
this paragraph, a claim for an authorized item or
service is a qualifying claim if it includes
information sufficient to establish that approval for
such item or service was provided as described in
subparagraph (B)(ii).''.
(b) Effect of Specified Authorizations.--Section 1857(e) of the
Social Security Act (42 U.S.C. 1395e-27(e)) is amended by adding at the
end the following new paragraph:
``(6) Effect of specified authorizations.--Beginning with
plan years beginning on or after January 1, 2028, a contract
under this section with an MA organization shall require that,
in the case that the MA organization approves the furnishing to
an individual enrolled under an MA plan offered by such MA
organization of an item or service through a specified
authorization (as defined in section 1852(g)(1)(C)(iii)) made
during the receipt by the individual of such item or service--
``(A) the MA organization may not, after such
approval, deny coverage of such item or service on the
basis of lack of medical necessity and may not reopen
such a decision for any reason except for good cause
(as described in sections 405.986 and 422.616 of title
42, Code of Federal Regulations (or any successor
regulation)) or if there is reliable evidence of fraud
or similar fault (as such terms are defined in section
405.902 of such title (or any successor regulation), as
determined in accordance with section 422.616 of such
title (or any successor regulation)); and
``(B) the MA organization may not, after such
approval, change the code assigned with respect to the
claim for such item or service such that the amount of
payment for such claim would be reduced, except for
good cause (as described in subparagraph (A)) or if
there is reliable evidence of fraud or similar fault
(as so described).''.
(c) Limitation on Use of Third-Party Post-Claim Review Entities.--
Section 1852(g) of the Social Security Act (42 U.S.C. 1395w-2(g)) is
amended by adding at the end the following new paragraph:
``(6) Limitations on use of third-party reviews.--
``(A) In general.--For contract years beginning on
or after January 1, 2028, procedures established by a
Medicare Advantage organization for making
determinations under paragraph (1), reconsiderations
under paragraph (2), or expedited determinations or
reconsiderations under paragraph (3), and procedures
established for providing for any post-payment review
process shall--
``(i) prohibit any third-party entity from
conducting a medical necessity review for
coverage, payment, or post-payment review for
such Medicare Advantage organization unless--
``(I) such review is not with
respect to an authorized item or
service (as defined in section
1857(f)(2)(B)); and
``(II) such entity is in compliance
with the requirements described in
subparagraph (B);
``(ii) prohibit the use of any third-party
review that is conducted using a routine,
automated process for denials in any such
review, claim denials, or pattern-based
practices of changing a code assigned with
respect to a claim for an item or service
furnished to individuals enrolled under an MA
plan offered by the Medicare Advantage
organization to a code that would result in a
reduction in the amount of payment for such
claim after the item or service has been
furnished to the individual; and
``(iii) prohibit any compensation
arrangement with any third-party entity that
provides for payment or other compensation to
such entity based on the number, percentage, or
amount of specified authorization requests (as
defined in section 1852(g)(1)(C)(iii)) that the
entity approves, denies, or otherwise
recommends for approval or denial.
``(B) Requirements.--For purposes of subparagraph
(A), the requirements specified in this subparagraph,
with respect to a third-party entity and a review
described in such subparagraph, are each of the
following:
``(i) The entity conducts such review in
accordance with audit protocols and appeal
rights, as applicable, that are specified by
the Secretary.
``(ii) The entity complies with audit and
public transparency reporting requirements
specified by the Secretary.''.
SEC. 5. COVERAGE AND MEDICAL NECESSITY CRITERIA USED BY MEDICARE
ADVANTAGE ORGANIZATIONS.
(a) Codification Under the Medicare Advantage Program of Two-
Midnight Benchmark and Presumption Rules.--Section 1852(g)(1) of the
Social Security Act (42 U.S.C. 1395w-22(g)(1)), as amended by section
2, is further amended by adding at the end the following new
subparagraph:
``(E) Application of two-midnight rules.--The
procedures under subparagraph (A) shall provide that,
for making determinations described in such
subparagraph with respect to hospital and critical
access hospital admissions--
``(i) in determining whether an individual
is an inpatient of a hospital or critical
access hospital, the Medicare Advantage
organization shall continue to apply the
provisions of section 412.3(d) of title 42,
Code of Federal Regulations, or any successor
regulation, in the same manner and to the same
extent as such provisions apply with respect to
payment under part A; and
``(ii) beginning on January 1, 2028, in
conducting medical review activities, with
respect to such admissions, the Medicare
Advantage organization shall apply the 2-
midnight presumption finalized in the rule
published by the Secretary in the Federal
Register on August 19, 2013 (78 Fed. Reg.
50952), or any successor regulation, in the
same manner and to the same extent as such
provisions apply with respect to payment under
part A.''.
(b) Requiring Consistent Medical Necessity Criteria Between
Medicare Advantage and Original Fee-for-Service.--
(1) In general.--Section 1852(g) of the Social Security Act
(42 U.S.C. 1395w-22(g)), as amended by section 4(c), is further
amended--
(A) in paragraph (2)(B), by striking ``A
reconsideration relating'' and inserting ``In
accordance with paragraph (7)(C), a reconsideration
relating''; and
(B) by adding at the end the following new
paragraph:
``(7) Medical necessity determined based on ffs reasonable
and necessary criteria.--
``(A) In general.--For purposes of a determination
or reconsideration under this subsection made on or
after January 1, 2028, or a review made on or after
such date by an independent, outside entity under
paragraph (4), with respect to coverage for an item or
service furnished to an individual enrolled in an MA
plan offered by a Medicare Advantage organization, the
Medicare Advantage organization or independent, outside
entity, respectively, shall not apply criteria for
determining the medical necessity of such item or
service that is more restrictive than the standards and
criteria applied pursuant to section 1862(a)(1) for
determining under parts A and B whether the item or
service is reasonable and necessary.
``(B) Certain coverage criteria.--For purposes of a
determination or reconsideration under this subsection
made on or after January 1, 2028, or a review made on
or after such date by an independent, outside entity
under paragraph (4), with respect to coverage of
inpatient hospital services furnished by a
rehabilitation facility (as referred to in section
1866(j)(1)(A)) or long-term care hospital to an
individual enrolled in an MA plan offered by a Medicare
Advantage organization, the Medicare Advantage
organization or independent, outside entity,
respectively, shall not apply coverage criteria that is
more restrictive than the standards and criteria
applied under parts A and B, including under--
``(i) subsections (a)(3), (a)(4), and
(a)(5) of section 412.622 of title 42, Code of
Federal Regulations (or any successor to such
regulation), with respect to such a
rehabilitation facility; and
``(ii) paragraphs (1), (3), and (4) of
section 1861(ccc) and clauses (iii) and (iv) of
section 1886(m)(6)(A), with respect to a long-
term care hospital.
``(C) Personnel.--For purposes of subparagraph (A),
a determination, reconsideration, or review regarding
the medical necessity of an item or service shall be
made only by a physician or other health care
professional with appropriate expertise, including
education, with respect to such item or service and the
related standards and criteria applied pursuant to
section 1862(a)(1). For purposes of subparagraph (B), a
determination, reconsideration, or review regarding
coverage of inpatient hospital services furnished by a
facility or hospital described in such subparagraph
shall be made only by a physician or other health care
professional with appropriate expertise, including
education, with respect to such services and the
related standards and criteria applied pursuant to such
subparagraph.''.
(2) Enforcement.--Section 1857(g)(1) of the Social Security
Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(A) by redesignating subparagraph (K) as
subparagraph (L);
(B) by striking ``or'' at the end of subparagraph
(J);
(C) by inserting after subparagraph (J) the
following subparagraph:
``(K) fails to comply with section 1852(g)(7);
or'';
(D) in subparagraph (L), as redesignated by
subparagraph (A), by striking ``subparagraphs (A)
through (J)'' and inserting ``subparagraphs (A) through
(K)''; and
(E) in the matter following such subparagraph (L),
by striking ``subparagraphs (A) through (K)'' and
inserting ``subparagraphs (A) through (L)''.
(c) Requiring Transparency in Coverage Criteria.--Section
1852(a)(2) of the Social Security Act (42 U.S.C. 1395w-22(a)(2)) is
amended by adding at the end the following new subparagraph:
``(D) Transparency in coverage criteria.--
``(i) Requirement.--For plan years
beginning on or after January 1, 2028, in order
to meet the requirement under paragraph (1)(A),
in the case of an item or service for which
there is no national coverage determination,
applicable local coverage determination, or
applicable guidance for coverage provided by
the Secretary, a Medicare Advantage
organization offering an MA plan shall--
``(I) make a coverage determination
with respect to such item or service in
accordance with publicly available
evidence-based coverage criteria that
is published on a public website of the
Medicare Advantage organization; and
``(II) submit to the Secretary
information, with respect to every
medical necessity determination made in
the absence of such national coverage
determination, applicable local
coverage determination, or applicable
guidance for coverage, specifying the
coverage criteria applied under the MA
plan.
``(ii) Use of information.--The Secretary
shall use the information submitted under
clause (i)(II) to prioritize coverage
determinations.''.
SEC. 6. ELIMINATING INEFFICIENCIES IN ADMINISTRATIVE PROCESSING BY
MEDICARE ADVANTAGE ORGANIZATIONS.
(a) Applying Fee-for-Service Prompt Payment Requirements to MA In-
Network Services as Well as Out-of-Network Services.--Section
1857(f)(1) of the Social Security Act (42 U.S.C. 1395w-27(f)(1)), as
amended by section 4(a), is further amended--
(1) in the paragraph heading, by inserting ``in-network
and'' before ``out-of-network''; and
(2) by striking ``if the services or supplies'' and all
that follows through the period at the end and inserting
``regardless of whether the services or supplies are furnished
under a contract between the organization and the provider of
services or supplier. A claim that is determined to be a clean
claim pursuant to the previous sentence or paragraph (2) may
not subsequently be determined to not be a clean claim except
under such circumstances and in accordance with such criteria
as specified by the Secretary pursuant to notice and comment
rulemaking.''.
(b) Automated Review and Payment for Certain Claims.--Section
1857(f) of the Social Security Act (42 U.S.C. 1395w-27(f)), as amended
by section 4(a), is further amended--
(1) by redesignating paragraphs (3) and (4) as paragraphs
(4) and (5), respectively; and
(2) by inserting after paragraph (2) the following new
paragraph:
``(3) Automated review and payment for certain claims.--
``(A) In general.--For plan years beginning on or
after January 1, 2028, a Medicare Advantage
organization shall have in place automated payment
processes, in accordance with standards specified by
the Secretary, for claims described in subparagraph (B)
with respect to which the provisions of paragraph (1)
or (2) apply. Such processes shall provide that such
claims shall be automatically processed and paid and
shall not be subject to manual claim review, except in
cases for which there is reasonable evidence of fraud.
``(B) Specified claims.--For purposes of
subparagraph (A), a claim described in this
subparagraph is a claim that--
``(i) is for an authorized item or service
(as defined in paragraph (2)(B)); or
``(ii) is for an item or service identified
on the most recent list published pursuant to
section 1852(g)(1)(D)(iii).''.
SEC. 7. MODIFICATION TO NETWORK ADEQUACY STANDARDS FOR CERTAIN POST-
ACUTE CARE PROVIDERS.
Section 1852(d)(1) of the Social Security Act (42 U.S.C. 1395w-
22(d)(1)) is amended--
(1) in subparagraph (D), by striking ``and'' at the end;
(2) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(F) for plan years beginning on or after January
1, 2028, the organization provides adequate access to
long-term care hospitals and inpatient rehabilitation
facilities, as determined in accordance with network
adequacy standards specified by the Secretary.''.
<all>Official legislative text sourced from the public record (cached on CivicsHQ).
Official source
View the original bill, actions, and full legislative record on Congress.gov.
Status
In Committee
- 1Introduced
- 2Committee
- 3Floor
- 4Passed
- 5Signed
Timeline reflects current normalized status only. Full action history is not yet stored in the API.
Sponsors
- Rep. Joyce, John [R-PA-13]RHousePA
Cosponsors
- Del. Norton, Eleanor Holmes [D-DC-At Large]
- Rep. Bera, Ami [D-CA-6]
- Rep. Budzinski, Nikki [D-IL-13]
- Rep. Carter, Troy A. [D-LA-2]
- Rep. Ciscomani, Juan [R-AZ-6]
- Rep. Davids, Sharice [D-KS-3]
- Rep. Davis, Donald G. [D-NC-1]
- Rep. Goodlander, Maggie [D-NH-2]
- Rep. Lawler, Michael [R-NY-17]
- Rep. Mann, Tracey [R-KS-1]
- Rep. Messmer, Mark B. [R-IN-8]
- Rep. Miller-Meeks, Mariannette [R-IA-1]
- Rep. Murphy, Gregory F. [R-NC-3]
- Rep. Onder, Robert F. [R-MO-3]
- Rep. Panetta, Jimmy [D-CA-19]
- Rep. Pfluger, August [R-TX-11]
- Rep. Schmidt, Derek [R-KS-2]
- Rep. Schrier, Kim [D-WA-8]
- Rep. Scott, Austin [R-GA-8]
- Rep. Van Duyne, Beth [R-TX-24]
Votes
Voting records are not yet available for this bill.