To amend title XVIII of the Social Security Act to establish certain requirements with respect to rates of reversed prior authorization coverage determinations under Medicare Advantage plans.
Sponsored By: Representative Pocan, Mark [D-WI-2]
Introduced
Summary
Tightens penalties on Medicare Advantage plans that have high rates of prior-authorization denials later overturned. This bill would create a new rule letting the Secretary terminate a Medicare Advantage contract when a plan exceeds an allowable rate of reversed prior-authorization coverage determinations.
Show full summary
- Medicare Advantage plans. Plans that impose prior authorization would risk contract termination if more than 25% of their prior-authorization coverage determinations initially deny coverage and are later reversed on reconsideration or appeal. This standard would apply to plan years beginning one year after enactment.
- Review-and-reconsideration monitoring. The bill also triggers termination if the Secretary finds a significant drop in the number of determinations reconsidered and reversed compared with the prior year, when that drop occurred because the plan failed to appropriately reconsider decisions.
- Enforcement mechanics. It adds the new reversal-rate requirement to section 1857(e) and adjusts certain contract-termination language so the Secretary can act under the new standard.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 1 benefits, 0 costs, 0 mixed.
New limits on Medicare Advantage denials
This bill would set a limit on bad prior-authorization denials in Medicare Advantage. Starting with plan years that begin one year after enactment, the Secretary of Health and Human Services would end a plan if more than 25% of its prior-authorization determinations start as denials and are later overturned on reconsideration or appeal. If a plan shows far fewer overturned reconsiderations than last year because it did not review cases properly, the Secretary would also end the plan. This would apply only to plans that require prior authorization.
Sponsors & CoSponsors
Sponsor
Pocan, Mark [D-WI-2]
WI • D
Cosponsors
Carson
IN • D
Sponsored 11/18/2025
Cohen
TN • D
Sponsored 11/18/2025
Rep. DeLauro, Rosa L. [D-CT-3]
CT • D
Sponsored 11/18/2025
Rep. Doggett, Lloyd [D-TX-37]
TX • D
Sponsored 11/18/2025
Rep. Jayapal, Pramila [D-WA-7]
WA • D
Sponsored 11/18/2025
Khanna
CA • D
Sponsored 11/18/2025
Del. Norton, Eleanor Holmes [D-DC-At Large]
DC • D
Sponsored 11/18/2025
Ocasio-Cortez
NY • D
Sponsored 11/18/2025
Schakowsky
IL • D
Sponsored 11/18/2025
Rep. Takano, Mark [D-CA-39]
CA • D
Sponsored 11/18/2025
Rep. Thanedar, Shri [D-MI-13]
MI • D
Sponsored 11/18/2025
Rep. Tlaib, Rashida [D-MI-12]
MI • D
Sponsored 11/18/2025
Rep. Johnson, Julie [D-TX-32]
TX • D
Sponsored 11/18/2025
McBride
DE • D
Sponsored 11/18/2025
Rep. Omar, Ilhan [D-MN-5]
MN • D
Sponsored 11/18/2025
Rep. Dingell, Debbie [D-MI-6]
MI • D
Sponsored 11/20/2025
Rep. Casar, Greg [D-TX-35]
TX • D
Sponsored 12/1/2025
Pingree
ME • D
Sponsored 12/16/2025
Roll Call Votes
No roll call votes available for this bill.
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