Medicare Advantage Improvement Act of 2026
- Bill Number
- H.R. 8375
- Origin Chamber
- House
- Congress
- 119th Congress, Session 2
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2026-04-27: Sponsor introductory remarks on measure. (CR H3095)
- Last Updated
- 2026-07-10T08:06:30Z
AI-Generated Summary
Purpose
The Medicare Advantage Improvement Act of 2026 (H.R. 8375) aims to reform the Medicare Advantage (MA) program—an alternative to traditional Medicare run by private insurers—by speeding up access to care, strengthening oversight, limiting unfair claim denials, aligning coverage rules with traditional Medicare, improving administrative efficiency, and ensuring better networks for post-acute care.
Key Provisions
- Timely Prior Authorizations (Sec. 2):
- Requires MA plans to respond to "specified authorizations" (prior approvals or concurrent reviews for items/services, including hospital transfers) within 72 hours (standard) or 24 hours (expedited) starting January 1, 2028; extensions up to 7 days allowed in limited cases.
- Mandates real-time approvals (immediate automated decisions) for low-risk, high-approval services via electronic health records (EHR), with annual Secretary lists of such services.
- Bans prior authorizations for clinically necessary changes/extensions to approved services.
- Speeds up reconsiderations (appeals): MA plans have 14 days to forward affirmed denials; independent reviewers decide in 7-30 days (or 24 hours expedited).
- Increases transparency: Public reporting of prior authorization data by plan/organization, downloadable for research.
- Oversight and Accountability (Sec. 3):
- Creates MAO Compliance Program: Scores plans (0-100) on categories like timely authorizations, coverage criteria, prompt payments, and marketing; low scores (below 90) trigger 1-2% payment reductions to MA organizations starting 2028.
- Adds Compliance and Coverage Protection Domain to MA Star Ratings, with heavier weighting; uses audits, complaints, and appeals data.
- Limits on Claim Denials/Clawbacks (Sec. 4):
- Requires 100% prompt payment (like traditional Medicare) for authorized services, treating them as "clean claims."
- Prohibits post-approval denials for medical necessity or payment downgrades (e.g., code changes reducing payment) except for fraud/good cause.
- Restricts third-party reviewers: No routine automated denials; no pay based on denial volume; limited to non-authorized services.
- Medical Necessity and Coverage Rules (Sec. 5):
- Codifies two-midnight rule for hospital stays (presumes inpatient if crossing 2 midnights).
- MA plans cannot use stricter medical necessity criteria than traditional Medicare's "reasonable and necessary" standard under Part A/B.
- Requires public disclosure of evidence-based criteria; reports to Secretary for prioritization.
- Administrative Efficiencies (Sec. 6):
- Extends prompt payment rules to in-network providers.
- Mandates automated processing/payment for authorized/low-risk claims, no manual review except fraud suspicions.
- Network Adequacy (Sec. 7):
- Requires access to long-term care hospitals and inpatient rehabilitation facilities per Secretary standards, starting 2028.
Significant Changes to Existing Law
- Shortens prior authorization timelines from current standards (e.g., 14 days standard).
- Introduces real-time approvals and compliance-based financial penalties (new).
- Aligns MA medical necessity/coverage with traditional Medicare (previously more flexible for plans).
- Bans routine post-approval clawbacks and limits third-party audits (stricter than current rules).
- Expands Star Ratings and adds payment reductions tied to compliance scores.
Potential Impacts
- Beneficiaries: Faster care access, fewer delays/denials; better protection against surprise non-coverage.
- MA Organizations: Higher admin costs, potential premium increases; incentives for compliance to avoid penalties.
- Providers: Quicker payments, reduced prior auth burden; easier access for post-acute care.
- Government (CMS): Increased oversight/enforcement workload; tools for transparency and data-driven improvements.
- No direct international relations impact.
Main Stakeholders Affected
- Medicare Advantage enrollees (over 30 million seniors/disabled).
- MA organizations (private insurers like UnitedHealth, Humana).
- Healthcare providers (hospitals, rehab facilities, physicians).
- Centers for Medicare & Medicaid Services (CMS) (regulates/enforces).
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens enforcement via civil penalties for non-compliance; codifies regulations (e.g., two-midnight rule) into statute for stability; requires notice-and-comment rulemaking for lists/timelines.
- Constitutional: None identified; operates within Congress's spending power over Medicare.
- Political: Bipartisan (7 sponsors); addresses criticisms of MA over-denials while preserving private option; most changes phased in 2028-2030.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (16)
Rep. Schrier, Kim [D-WA-8], Rep. Murphy, Gregory F. [R-NC-3], Rep. Panetta, Jimmy [D-CA-19], Rep. Miller-Meeks, Mariannette [R-IA-1], Rep. Bera, Ami [D-CA-6], Rep. Van Duyne, Beth [R-TX-24], Rep. Davis, Donald G. [D-NC-1], Rep. Mann, Tracey [R-KS-1], Del. Norton, Eleanor Holmes [D-DC-At Large], Rep. Lawler, Michael [R-NY-17], Rep. Messmer, Mark B. [R-IN-8], Rep. Davids, Sharice [D-KS-3], Rep. Scott, Austin [R-GA-8], Rep. Carter, Troy A. [D-LA-2], Rep. Budzinski, Nikki [D-IL-13], Rep. Ciscomani, Juan [R-AZ-6]
Recent Actions
- 2026-04-27: Sponsor introductory remarks on measure. (CR H3095)
- 2026-04-20: 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.
- 2026-04-20: 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.
- 2026-04-20: Introduced in House
- 2026-04-20: Introduced in House
Bill Versions
- Medicare Advantage Improvement Act of 2026 — issued 2026-04-20 — PDF (44 pages)