A bill to amend title XVIII of the Social Security Act to provide for certain reforms under the Medicare Advantage program, and for other purposes.

Bill Number

S. 4384

Origin Chamber

Senate

Congress

119th Congress, Session 2

Status

Introduced

Latest Action

2026-04-27: Read twice and referred to the Committee on Finance.

Last Updated

2026-04-28T10:56:40Z

AI-Generated Summary

Medicare Advantage Improvement Act of 2026 (S. 4384)

Purpose

This bill aims to reform the Medicare Advantage (MA) program under Medicare Part C by speeding up access to care, strengthening oversight of MA organizations (private insurers offering MA plans), limiting improper claim denials, aligning coverage rules with traditional Medicare (fee-for-service or FFS), and improving payment processes. Most changes apply to plan years starting January 1, 2028.

Key Provisions

• Timely Prior Authorizations (Sec. 2):
• MA plans must respond to most prior authorization requests (called "specified authorizations," including pre-service approvals and concurrent reviews) within 72 hours (standard) or 24 hours (expedited).
• Allows 7-day extensions in limited cases (e.g., needing more evidence).
• Mandates real-time approvals via electronic health records (EHR) for routine, low-risk services with high approval rates (90%+), published annually by HHS.
• Bans new authorizations for clinically necessary extensions or changes to already-approved services (though documentation can still be required).
• Improves reconsideration timelines (e.g., 14 days for MA response) and independent reviews (e.g., 7-30 days depending on service type).
• Requires public reporting of prior authorization data by plan and parent organization.

• Oversight and Accountability (Sec. 3):
• Creates an MAO Compliance Program scoring MA organizations (0-100 scale) across categories like timely authorizations, coverage criteria, prompt payments, and marketing.
• Assigns tiers with payment reductions: 1% (75-89 score), 1.5% (60-74), 2% (<60).
• Adds a Compliance and Coverage Protection Domain to MA Star Ratings, weighted higher than others, using audits, complaints, and appeals data.

• Limits on Retrospective Denials (Sec. 4):
• Requires 100% prompt payment (per FFS rules) for all authorized services, treating them as "clean claims."
• Bans post-approval denials for lack of medical necessity or code downgrades (reducing payment), except for fraud or "good cause" (e.g., errors).
• Restricts third-party reviewers: no routine automated denials, no incentive-based pay tied to denials, and only for non-authorized services.

• Coverage and Medical Necessity Standards (Sec. 5):
• MA plans must use FFS Medicare criteria for medical necessity (no stricter rules), including "two-midnight" hospital stay presumption.
• Coverage decisions by qualified physicians; specific rules for rehab facilities and long-term care hospitals.
• Requires public posting of evidence-based criteria and reporting to HHS.

• Administrative Efficiencies (Sec. 6):
• Extends prompt payment to in-network services.
• Mandates automated processing/payment for authorized or routine claims (no manual review except fraud suspicion).

• Network Adequacy (Sec. 7):
• Requires access to long-term care hospitals and inpatient rehabilitation facilities per HHS standards.

Significant Changes to Existing Law

• Amends Social Security Act sections 1852 (benefits, determinations), 1853 (payments), 1857 (contracts).
• Shortens timelines: From prior 14-day standard/72-hour expedited to 72/24 hours for most cases.
• Codifies protections: Locks in FFS medical necessity rules (previously voluntary), bans routine retroactive denials (previously allowed), adds compliance penalties and Star Ratings domain.
• Expands reporting/transparency: Plan-level data, real-time metrics, public websites.
• Shifts from contract-level to plan/parent organization reporting.

Potential Impacts

• MA Enrollees (Citizens): Faster care approvals, fewer delays/denials, better protection against surprise non-coverage.
• Healthcare Providers/Suppliers: Quicker payments, reduced admin burden from real-time tools and auto-payments.
• MA Organizations: Higher compliance costs (tech upgrades, training), risk of payment cuts (up to 2%), pressure to improve Star Ratings.
• Government Agencies (CMS/HHS): Increased workload for rulemaking, audits, data analysis, enforcement; potential savings from efficiencies but more oversight resources needed.
• No direct impacts on international relations.

Main Stakeholders Affected

• Primary: MA enrollees (over 30 million seniors/disabled), MA organizations (e.g., UnitedHealth, Humana), hospitals, physicians, post-acute providers.
• Secondary: CMS (oversight/enforcement), HHS Secretary (rulemaking), independent review entities.

Notable Legal, Constitutional, or Political Implications

• Legal: Strengthens enrollee/provider rights via enforceable timelines and FFS alignment; adds civil monetary penalties for non-compliance. Relies on notice-and-comment rulemaking for flexibility (e.g., lists, scores).
• Constitutional: None apparent; operates within Congress's spending power over Medicare.
• Political: Bipartisan sponsors (Sens. Marshall, Whitehouse); addresses criticisms of MA overpayments/denials vs. traditional Medicare, potentially reducing program costs while protecting beneficiaries. May face industry pushback over penalties/tech mandates.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Sen. Marshall, Roger [R-KS]

Cosponsors (1)

Sen. Whitehouse, Sheldon [D-RI]

Recent Actions

• 2026-04-27: Read twice and referred to the Committee on Finance.
• 2026-04-27: Introduced in Senate

Bill Versions

• Medicare Advantage Improvement Act of 2026 — issued 2026-04-27 — PDF (44 pages)