Medicare Advantage Improvement Act of 2026
Sponsored By: Senator Sen. Marshall, Roger [R-KS]
Introduced
Summary
Faster, fairer prior authorization and stronger oversight of Medicare Advantage plans. This bill would require Medicare Advantage organizations to speed up and automate prior authorization decisions, limit retroactive denials and coding changes, and link compliance to payment penalties and star ratings.
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- Families and enrollees: Decisions on many authorization requests would be faster, with standard deadlines of no later than 72 hours and expedited reviews as fast as 24 hours for urgent cases. The bill also blocks new authorizations during clinically necessary in-service changes so care is less likely to be interrupted.
- Providers and suppliers: The bill would create a real-time authorization system tied to certified electronic health record technology and require automated processing and prompt payment of authorized claims, treating qualifying claims as clean claims and applying a 100 percent prompt-payment standard.
- Medicare Advantage organizations: Plans would face a new compliance score and four-tier accountability system that can cut monthly payments by 1.0, 1.5, or 2.0 percent for lower-performing tiers and add a compliance domain to Star Ratings.
The bill would also require broad public reporting of prior authorization and compliance data to improve oversight.
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Bill Overview
Analyzed Economic Effects
6 provisions identified: 6 benefits, 0 costs, 0 mixed.
Align medical-necessity with Medicare
If enacted, Medicare Advantage plans would have to use medical-necessity rules no more restrictive than Original Medicare for decisions and appeals starting January 1, 2028. The bill would codify the Part A two-midnight inpatient presumption for hospital admission reviews. When no national or local Medicare rule exists, plans would have to publish evidence-based coverage criteria on their public website and send the criteria to CMS for each such decision.
Faster automated Medicare Advantage payments
If enacted, Medicare Advantage plans would have to use automated processing and payment for certain authorized claims starting January 1, 2028. Claims for authorized items or services would be treated as clean claims (100%) for prompt-payment rules and must be paid automatically unless there is reasonable evidence of fraud. The bill would extend fee-for-service prompt-payment standards to in-network and out-of-network services for these qualifying claims.
New Medicare Advantage compliance scores
If enacted, each Medicare Advantage plan would get a public compliance score from 0–100 starting in plan years on or after January 1, 2028. Plans would be put into four tiers (90+, 75–89, 60–74, below 60). Plans in lower tiers could face monthly payment cuts of about 1.0%, 1.5%, or 2.0% to their monthly payments. CMS would let plans review scores before they are published.
Protections after Medicare Advantage approval
If enacted, a plan generally could not deny coverage or reduce payment after it already approved a service through prior authorization, starting in plan years on or after January 1, 2028. Exceptions would be limited to good cause or reliable evidence of fraud. The bill would also restrict third-party post-payment and medical-necessity reviews for authorized services and ban reviewer pay tied to denial volumes.
Real-time prior authorization rules
If enacted, Medicare Advantage plans would have to give fast answers for certain prior authorization requests starting January 1, 2028. Routine authorization requests must be decided no later than 72 hours and expedited requests no later than 24 hours, with only narrow 7‑day extensions. Plans would build real-time, certified EHR tools for items on a yearly list (items with at least 90% prior-year approval). Plans must report quarterly results and CMS would publish the data.
Medicare Advantage post-acute network rules
If enacted, Medicare Advantage plans would have to meet network adequacy standards that ensure access to long-term care hospitals and inpatient rehabilitation facilities starting in plan years on or after January 1, 2028. CMS would set the standards that define adequate access.
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Sponsors & CoSponsors
Sponsor
Sen. Marshall, Roger [R-KS]
KS • R
Cosponsors
Sen. Whitehouse, Sheldon [D-RI]
RI • D
Sponsored 4/27/2026
Roll Call Votes
No roll call votes available for this bill.
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