Medicare Advantage Improvement Act of 2026
Sponsored By: Senator Marshall, Roger [R-KS]
Introduced
Summary
This bill would require faster, more transparent prior authorization for Medicare Advantage and create a public MAO compliance score that can cut payments. It focuses on strict time limits, real-time approvals for routine services, stronger review by an outside entity, and broad public reporting.
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- Medicare beneficiaries and their clinicians would face quicker decisions. The bill would mandate decisions for many prior-authorizations within 72 hours and expedited cases within 24 hours. It would also bar prior authorization for clinically necessary in-course extensions and require network adequacy for long-term care hospitals and inpatient rehabilitation facilities.
- Medicare Advantage organizations and plans would face new enforcement. The bill would create a 0–100 compliance score and four tiers with payment cuts, up to a 2.0% reduction for the lowest tier. Plans would also need automated payment processes for specified low-risk or high-volume claims.
- CMS, researchers, and the public would get more data and faster oversight. Plans would report real-time determination data quarterly at plan, MAO, and parent levels. Denied cases could move to an independent outside reviewer with short submission windows and decisions as fast as 24 hours.
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Bill Overview
Analyzed Economic Effects
5 provisions identified: 4 benefits, 0 costs, 1 mixed.
Faster prior authorizations and data
If enacted, this bill would require Medicare Advantage plans to give faster prior authorization decisions and publish data about those decisions. Starting January 1, 2028, standard requests would get a notice no later than 72 hours and expedited requests no later than 24 hours, with limited 7-day extensions in narrow situations. Plans would have to provide real-time approvals through certified electronic health record systems for items on the Secretary's annual list and automate payment for approved items in plan years beginning January 1, 2028. The Secretary would also require quarterly, downloadable reporting of prior-authorization and real-time decision counts, approvals, denials, appeals, overturns, and provider complaints by plan and provider type.
Limits on outside reviewer denials
If enacted, this bill would restrict outside companies that review medical necessity for Medicare Advantage plans starting January 1, 2028. Plans would have to stop routine automated denial processes and pattern-based post-service code changes that reduce payment. Plans could not pay outside reviewers based on the number or share of approvals or denials. Third-party reviewers would need to follow Secretary-set audit protocols, appeals, and public reporting rules.
Stronger inpatient and post-acute rules
If enacted, this bill would strengthen how Medicare Advantage plans handle hospital and post-acute care. For plan years beginning January 1, 2028, plans would have to meet Secretary-set network adequacy rules for long-term care hospitals and inpatient rehabilitation facilities. Plans and reviewers would not be allowed to use medical-necessity rules that are stricter than traditional Medicare Parts A and B, and only qualified clinicians could make those decisions. Plans would also have to apply the Part A two-midnight presumption for inpatient admissions starting January 1, 2028.
New Medicare Advantage compliance penalties
If enacted, this bill would create a Compliance Scoring and Accountability Program for Medicare Advantage organizations and publish scores and methods. MAOs would get a 0–100 score and fall into four tiers. For plan years beginning January 1, 2028, plans in Tier 2 would have monthly payments cut by 1.0 percent, Tier 3 by 1.5 percent, and Tier 4 by 2.0 percent. The Secretary would set scoring categories and let MAOs review scores before public disclosure.
Faster outside reviews for denials
If enacted, this bill would speed external reviews when a Medicare Advantage plan upholds a denial. For reconsiderations on or after January 1, 2028, the plan would have to send the case to a Secretary-contracted outside reviewer within 14 days. The reviewer would notify the enrollee, representative, and provider within 3 days, allow 7 days for new records, and then decide quickly: within 14 days for most coverage, 7 days for Part B drug coverage, 30 days for payment issues, and 24 hours for expedited reviews.
Sponsors & CoSponsors
Sponsor
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.
View on Congress.gov