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DOL Rewrites Disability Rules for 'Merit-Based Opportunity' Push
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HR8375119th CongressWALLET
Medicare Advantage Improvement Act of 2026
Sponsored By: Representative Joyce, John [R-PA-13]
Introduced
Summary
Faster prior authorizations and stronger plan accountability. This bill would force Medicare Advantage plans to speed and standardize authorization decisions while creating a public compliance scoring program tied to payment adjustments and transparency rules.
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- Beneficiaries and providers would get quicker decisions. Plans must notify on prior authorization requests within 72 hours with one extension up to 7 days. Plans must also implement annual real‑time determination mechanisms for frequently approved, low‑risk services and report quarterly, provider‑level data to CMS for public release.
- Medicare Advantage organizations would face a new Compliance Scoring and Accountability Program that rates plans on a 0–100 scale and places them in tiers. Poor performance can reduce monthly payments by up to 2.0% during the plan year and scores would be published for public review.
- Claims, networks, and transparency would change. Prompt‑payment rules would apply to in‑network services. Plans must automate payment for certain authorized claims and meet new network adequacy standards for long‑term care hospitals and inpatient rehabilitation facilities.
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Bill Overview
Analyzed Economic Effects
4 provisions identified: 3 benefits, 0 costs, 1 mixed.
Faster authorizations and automatic payments
If enacted, the bill would require faster decisions and more automatic payments for many prior authorizations beginning January 1, 2028. CMS would publish a yearly list of routine, low-risk services (items with at least 90% prior-authorization approval) that must get real-time decisions through certified electronic health records. MA plans would have to use automated payment processes for authorized services or items on that list, with manual review allowed only for reasonable evidence of fraud. The bill would also treat qualifying claims for authorized services as "clean" claims and apply fee-for-service prompt payment rules (treating a 95% benchmark as 100%).
Protections for approved care and appeals
If enacted, the bill would limit retroactive denials and harder code changes for services that were approved during care starting January 1, 2028. Plans would not be able to require a new authorization when a provider makes a clinically necessary change or extension to an already-approved service. Determinations, reconsiderations, and reviews would use medical necessity standards no more restrictive than Parts A and B and must be done by clinicians with appropriate expertise. For reconsiderations, independent outside entities would have to notify parties within 3 days, allow 7 days to submit documents, and issue decisions within set deadlines (24 hours expedited, 7 days for drugs, 14 days for other coverage, 30 days for payment). The bill would also limit third-party outsourcing of medical necessity reviews and ban pay arrangements or routine automated denial patterns tied to approval or denial volume.
Medicare Advantage compliance scores and cuts
If enacted, the bill would create a 0–100 compliance score for each Medicare Advantage organization and put each into a tier for plan years starting January 1, 2028. CMS would publish plan-level scores and let plans review data before publication. Plans in lower tiers would face monthly payment reductions (tier two: 1.0%, tier three: 1.5%, tier four: 2.0%). The bill would also add a new compliance domain to Medicare star ratings and require that domain be weighted more than any other domain.
Better access to post-acute care
If enacted, the bill would require Medicare Advantage plans to meet new network adequacy standards that include long-term care hospitals and inpatient rehabilitation facilities for plan years starting January 1, 2028. The Secretary would set the specific network rules to ensure access to these post-acute settings.
Sponsors & CoSponsors
Sponsor
Joyce, John [R-PA-13]
PA • R
Cosponsors
Rep. Schrier, Kim [D-WA-8]
WA • D
Sponsored 4/20/2026
Rep. Murphy, Gregory F. [R-NC-3]
NC • R
Sponsored 4/20/2026
Rep. Panetta, Jimmy [D-CA-19]
CA • D
Sponsored 4/20/2026
Rep. Miller-Meeks, Mariannette [R-IA-1]
IA • R
Sponsored 4/20/2026
Rep. Bera, Ami [D-CA-6]
CA • D
Sponsored 4/20/2026
Rep. Van Duyne, Beth [R-TX-24]
TX • R
Sponsored 4/20/2026
Rep. Davis, Donald G. [D-NC-1]
NC • D
Sponsored 6/8/2026
Rep. Mann, Tracey [R-KS-1]
KS • R
Sponsored 6/23/2026
Del. Norton, Eleanor Holmes [D-DC-At Large]
DC • D
Sponsored 6/23/2026
Rep. Lawler, Michael [R-NY-17]
NY • R
Sponsored 6/23/2026
Rep. Messmer, Mark B. [R-IN-8]
IN • R
Sponsored 6/25/2026
Rep. Davids, Sharice [D-KS-3]
KS • D
Sponsored 6/25/2026
Rep. Scott, Austin [R-GA-8]
GA • R
Sponsored 6/25/2026
Rep. Carter, Troy A. [D-LA-2]
LA • D
Sponsored 7/9/2026
Rep. Budzinski, Nikki [D-IL-13]
IL • D
Sponsored 7/9/2026
Rep. Ciscomani, Juan [R-AZ-6]
AZ • R
Sponsored 7/9/2026
Rep. Pfluger, August [R-TX-11]
TX • R
Sponsored 7/13/2026
Rep. Schmidt, Derek [R-KS-2]
KS • R
Sponsored 7/20/2026
Rep. Onder, Robert F. [R-MO-3]
MO • R
Sponsored 7/21/2026
Rep. Goodlander, Maggie [D-NH-2]
NH • D
Sponsored 7/27/2026
Rep. Sorensen, Eric [D-IL-17]
IL • D
Sponsored 8/10/2026
Rep. Vasquez, Gabe [D-NM-2]
NM • D
Sponsored 8/13/2026
Rep. Kean, Thomas H. [R-NJ-7]
NJ • R
Sponsored 8/13/2026
Rep. Carson, André [D-IN-7]
IN • D
Sponsored 10/6/2026
Roll Call Votes
No roll call votes available for this bill.
View on Congress.gov