To amend title XVIII of the Social Security Act to require any advertisement of a Medicare Advantage plan to include information related to the rates of prior authorization denials under such plan.
- Bill Number
- H.R. 6111
- 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
- 2025-12-17T09:06:13Z
AI-Generated Summary
Purpose
This legislation, H.R. 6111, aims to increase transparency in Medicare Advantage (MA) plans—private health insurance options under Medicare—by requiring advertisements to disclose data on prior authorization denials. Prior authorization is a process where a health plan must approve certain treatments or services before they are covered. The goal is to help Medicare beneficiaries make informed decisions about plans by highlighting how often coverage requests are initially denied.
Key Provisions
- Disclosure Requirements: Starting one year after the bill's enactment, all advertisements for an MA plan must include both verbal and visual (where feasible) disclosures based on the most recent completed plan year.
- Specific Data to Disclose:
- The total number of prior authorization requests denied, including those that were later approved after reconsideration.
- The number of denied requests that were reconsidered and ultimately approved.
- The average number of days between the initial denial and approval for those reconsidered cases.
- The amendment adds a new paragraph (3) to Section 1852(c) of the Social Security Act, which governs MA plan operations.
Significant Changes to Existing Law
- This introduces a new mandatory disclosure rule for MA plan advertisements, which previously had no such requirement for prior authorization denial rates.
- It builds on existing MA plan regulations under Title XVIII of the Social Security Act but adds specificity to advertising standards, focusing on denial metrics to promote accountability without altering the core prior authorization process.
Potential Impacts
- On Citizens: Medicare beneficiaries (primarily seniors and people with disabilities) will gain clearer information during open enrollment or plan shopping, potentially leading to better choices and fewer surprises with denied care. This could reduce delays in accessing treatments.
- On Government Agencies: The Centers for Medicare & Medicaid Services (CMS) may need to update oversight and enforcement mechanisms to monitor compliance in advertisements, possibly increasing administrative workload.
- On International Relations: No direct impacts, as this is a domestic health policy focused on U.S. Medicare programs.
- Broader effects could include pressure on MA plans to reduce denial rates to improve their advertising appeal, potentially affecting healthcare access and costs.
Main Stakeholders Affected
- Medicare Beneficiaries: Primary beneficiaries who rely on MA plans for coverage and may face denials.
- MA Plan Insurers: Private companies offering MA plans (e.g., UnitedHealth, Humana) must revise advertisements and track denial data, facing compliance costs.
- Healthcare Providers: Doctors and facilities submitting prior authorization requests could see indirect benefits from fewer denials or faster appeals.
- Government Entities: CMS for enforcement; Congress for ongoing Medicare policy oversight.
- Advocacy Groups: Organizations representing seniors or patient rights may support or monitor implementation.
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens consumer protection under federal health law by mandating transparency, potentially reducing lawsuits over misleading ads. Enforcement would fall under existing CMS authority, with possible fines for non-compliance.
- Constitutional: No apparent challenges; it aligns with Congress's power to regulate interstate commerce and federal programs like Medicare.
- Political: Sponsored by progressive Democrats, it reflects bipartisan concerns about MA plan practices (e.g., high denial rates criticized in recent audits). It could spark debates on privatizing Medicare versus traditional fee-for-service options, influencing future healthcare reforms without major partisan divide.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (17)
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. 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 require any advertisement of a Medicare Advantage plan to include information related to the rates of prior authorization denials under such plan. — issued 2025-11-18 — PDF (3 pages)