Medicare Advantage Improvement Act of 2026
Sponsored By: Representative Joyce (PA)
Introduced
Summary
Speeds up and automates prior authorization while increasing accountability for Medicare Advantage plans. This bill would push plans to make faster decisions, deliver real-time approvals for routine services, strengthen payment protections, and publish compliance scores.
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Bill Overview
Analyzed Economic Effects
6 provisions identified: 5 benefits, 0 costs, 1 mixed.
Limits on post‑approval denials and reviewers
This bill would stop plans from reversing approvals after care was authorized, starting with plan years beginning Jan 1, 2028. Plans could only reopen or deny an approved item for good cause or reliable evidence of fraud. Third-party reviewers generally could not audit or deny services that were already authorized. The bill would also ban routine automated denial systems and bar paying reviewers based on how many denials they make.
Compliance scores, penalties, and stars
This bill would create a public Medicare Advantage compliance score (0–100) for plan years beginning Jan 1, 2028. Plans would be placed in tiers by score. Lower tiers would face monthly payment reductions (tier 2 = 1.0%, tier 3 = 1.5%, tier 4 = 2.0%). The Secretary would add a new Compliance and Coverage Protection domain to the star ratings and give it extra weight.
Faster approvals and automated payments
This bill would require faster prior authorization decisions and real-time electronic approvals for many routine services starting for plan years beginning Jan 1, 2028. Plans would have to decide standard requests within 72 hours, allow one limited 7-day extension, and notify expedited requests within 24 hours. The Secretary would publish an annual list of routine items (90% prior-year approval and low clinical risk) that must get real-time EHR-based determinations. For authorized or listed items, plans would automate claim processing and payment, with manual review allowed only for reasonable evidence of fraud.
Prior authorization transparency reporting
This bill would make plans report prior authorization and real‑time determination data beginning with plan years that start Jan 1, 2028. Reports must be at the plan and parent‑company level, comparable by provider and service, downloadable, and posted on the CMS website. Plans would submit quarterly real‑time counts and percentages for approvals, denials, appeals, overturns, and provider complaints.
Medical‑necessity parity and hospital rule
This bill would require Medicare Advantage plans and outside reviewers to use medical‑necessity standards no stricter than Medicare Fee‑for‑Service for decisions made on or after Jan 1, 2028. Decisions would have to be made by clinicians with appropriate expertise. The bill would also require plans to apply the two‑midnight presumption for hospital inpatient status in the same way as Part A when doing medical review starting Jan 1, 2028.
Network rules for post‑acute care access
This bill would require Medicare Advantage plans to meet network adequacy standards for long‑term care hospitals and inpatient rehabilitation facilities for plan years beginning Jan 1, 2028. The Secretary would define the standards to determine whether access is adequate.
Sponsors & CoSponsors
Sponsor
Joyce (PA)
PA • R
Cosponsors
Schrier
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
Van Duyne
TX • R
Sponsored 4/20/2026
Roll Call Votes
No roll call votes available for this bill.
View on Congress.gov