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.
- Bill Number
- H.R. 6109
- Origin Chamber
- House
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-11-18: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- Last Updated
- 2025-12-17T09:06:27Z
AI-Generated Summary
Purpose
This bill (H.R. 6109) aims to improve access to healthcare services for Medicare beneficiaries enrolled in Medicare Advantage (MA) plans by addressing improper denials of coverage through prior authorization processes. Prior authorization is a requirement where a health plan must approve certain items or services before they are provided. The legislation sets standards to penalize plans that frequently deny coverage initially but later reverse those decisions, ensuring plans make fair initial determinations.
Key Provisions
- New Requirement on Reversal Rates (Section 1857(e)(6)): Starting one year after enactment, MA plans using prior authorization must not exceed an "allowable rate" of reversed coverage determinations. If they do, the Secretary of Health and Human Services (via the Centers for Medicare & Medicaid Services, or CMS) must terminate the plan's contract.
- The allowable rate is exceeded if:
- More than 25% of initial coverage denials are later reversed through internal reconsideration (under section 1852(g)(2)) or external appeal (under section 1852(g)(5)).
- Or, if reversals drop significantly compared to the prior year because the plan failed to properly review denials during reconsideration.
- Defines "prior authorization coverage determination" as a decision under section 1852(g) on whether a beneficiary can receive an item or service after prior authorization is required.
- Amendment to Contract Termination Rules (Section 1857(h)(1)(A)): Excludes terminations due to high reversal rates from standard advance notice requirements, allowing for quicker action by CMS.
Significant Changes to Existing Law
- Introduces a specific performance threshold (25% reversal rate) for prior authorization denials, which did not previously exist in the Social Security Act. This creates a direct link between reversal rates and contract termination, unlike current rules that allow CMS to terminate contracts for other reasons (e.g., quality issues) but without this targeted metric.
- Adds a mechanism to monitor year-over-year changes in reversal rates, focusing on plans that might be skimping on internal reviews to reduce appeals.
- Streamlines termination processes for these violations by bypassing typical notice periods, making enforcement faster than under prior law.
Potential Impacts
- On Citizens (Medicare Beneficiaries): Could reduce delays and frustrations from unjustified denials, leading to timelier access to necessary medical items or services. Beneficiaries in non-compliant plans might need to switch plans if contracts are terminated, potentially disrupting care but improving overall plan accountability.
- On Government Agencies: Empowers CMS with a new tool to oversee MA plans more rigorously, potentially increasing administrative workload for monitoring reversal rates but enhancing enforcement of coverage rules.
- On Healthcare Providers: May encourage plans to approve more requests upfront, easing administrative burdens and allowing providers to deliver care without prolonged appeals.
- No direct impacts on international relations, as this is a domestic healthcare policy.
Main Stakeholders Affected
- Medicare Advantage Organizations/Plans: Primary targets, as they face contract termination risks and must adjust prior authorization processes to stay below the 25% reversal threshold.
- Medicare Beneficiaries: Enrollees in MA plans (about half of all Medicare users) benefit from potential reductions in improper denials but could face plan disruptions.
- Healthcare Providers and Suppliers: Those furnishing items/services under MA, who often navigate prior authorizations and could see fewer barriers.
- Federal Government (CMS): Gains authority to enforce compliance, affecting budgeting and oversight priorities.
- Advocacy Groups: Consumer and patient rights organizations may support this as a protection measure, while industry groups (e.g., insurers) might oppose it for increasing regulatory scrutiny.
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens CMS's regulatory authority under the Social Security Act by adding enforceable metrics for contract termination, potentially leading to more litigation if plans challenge reversal rate calculations or terminations. Ensures alignment with existing appeal processes (sections 1852(g)(2) and (g)(5)) without altering them.
- Constitutional: No apparent issues; it operates within Congress's spending power over Medicare and does not infringe on due process, as terminations follow statutory guidelines (though with expedited notice).
- Political: Reflects bipartisan concerns (introduced by Democrats but addresses widespread issues with MA denials) about private insurers' role in Medicare, potentially pressuring the MA industry to prioritize beneficiary access over cost-cutting. Could influence future healthcare reforms by setting a precedent for performance-based penalties in privatized programs.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (18)
Rep. Carson, André [D-IN-7], Rep. Cohen, Steve [D-TN-9], Rep. DeLauro, Rosa L. [D-CT-3], Rep. Doggett, Lloyd [D-TX-37], Rep. Jayapal, Pramila [D-WA-7], Rep. Khanna, Ro [D-CA-17], Del. Norton, Eleanor Holmes [D-DC-At Large], Rep. Ocasio-Cortez, Alexandria [D-NY-14], Rep. Schakowsky, Janice D. [D-IL-9], Rep. Takano, Mark [D-CA-39], Rep. Thanedar, Shri [D-MI-13], Rep. Tlaib, Rashida [D-MI-12], Rep. Johnson, Julie [D-TX-32], Rep. McBride, Sarah [D-DE-At Large], Rep. Omar, Ilhan [D-MN-5], Rep. Dingell, Debbie [D-MI-6], Rep. Casar, Greg [D-TX-35], Rep. Pingree, Chellie [D-ME-1]
Recent Actions
- 2025-11-18: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-11-18: Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-11-18: Introduced in House
- 2025-11-18: Introduced in House
Bill Versions
- 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. — issued 2025-11-18 — PDF (4 pages)