Sponsors (19)
Official title: To amend title XVIII of the Social Security Act to provide for certain reforms under the Medicare Advantage program, and for other purposes.
Introduced April 20, 2026 by John Joyce · Last progress April 20, 2026
The bill trades stronger, faster, and more transparent coverage decisions, payment certainty, and improved access for Medicare Advantage enrollees and providers against substantial compliance and IT costs, greater administrative complexity, reduced plan flexibility, and risks that those costs or constraints will be passed to beneficiaries or strain smaller plans and taxpayers.
Medicare beneficiaries (especially those with chronic conditions) will get faster, more reliable coverage decisions and fewer inappropriate denials because prior authorization timelines are shortened (72/24-hour standards), real‑time EHR-integrated determinations are required for routine services, in‑service modifications won’t require new authorizations, and inpatient/coverage standards are tied/
Providers and suppliers will receive faster, more predictable payments and smaller billing backlogs because qualifying authorized claims are treated as clean claims, subject to prompt‑payment requirements, and routine authorized claims are eligible for automated payment.
Consumers, providers, and researchers will get substantially greater transparency into prior authorization use, plan behavior, and coverage rules through quarterly public reporting, plan‑level compliance scores (integrated into Star Ratings), and publication/submission of evidence‑based coverage criteria.
Medicare Advantage organizations and their vendors will face substantial new IT, reporting, and compliance costs to implement real‑time EHR integration, automated payment systems, and expanded public reporting; those costs are likely to be passed to enrollees via premiums, narrower benefits, or reduced provider payments.
Smaller, rural, or low‑margin MA plans may be disproportionately harmed by new weighted scoring, reporting burdens, and network adequacy rules, risking plan exits or reduced plan choices for beneficiaries in affected areas.
Increased CMS oversight, audits, rulemaking, and public reporting will raise administrative costs for government and taxpayers, and limiting some review mechanisms could paradoxically increase improper payments or program exposure if enforcement or automation is imperfect.
Based on analysis of 7 sections of legislative text.
Standardizes MA prior authorization, claims payment, medical‑necessity, transparency, and network adequacy rules and creates a compliance scoring program with payment penalties starting Jan 1, 2028.
Requires Medicare Advantage plans to speed and standardize prior authorization, payment, and medical-necessity rules to align with Original Medicare, increases transparency, and creates a compliance scoring system that can reduce plan payments for poor performance. Many provisions take effect for plan years beginning January 1, 2028, including deadlines for certain authorization decisions, limits on retrospective denials, automated payment requirements, public posting of coverage criteria, and new network adequacy standards for long‑term care hospitals and inpatient rehabilitation facilities. Creates an HHS-administered MAO Compliance Program that scores plans and places them into tiers subject to monthly payment reductions; requires notice-and-comment rulemaking for many implementation details and gives the Secretary authority to adjust some deadlines in future rulemaking. The bill primarily changes how Medicare Advantage organizations handle authorizations, claims, medical necessity determinations, audits, and provider access rather than creating new benefit authorities or appropriations.