Sponsors (2)
The bill improves patient understanding and appeals of coverage denials and creates oversight data on denial rates, but it raises insurer administrative burdens and may expose proprietary criteria while producing summary reports that may lack actionable detail for affected patient groups.
Patients — especially those with chronic conditions and uninsured people — receive individualized denial notices that state which medical-necessity standard was applied, why the service was denied, and (by including the issuer’s criteria) give clinicians and patients clearer information to pursue appeals or second opinions.
Insurer transparency is increased through annual reporting of denial rates to the Secretary, creating data that supports oversight and potential policy action to identify excessive denial practices.
Insurers will face added administrative costs to produce individualized notices and annual reports, which could be passed on to consumers through higher premiums or reduced benefits.
Requiring disclosure of detailed medical-necessity standards may expose proprietary utilization‑management criteria and provoke disputes over clinical judgment, increasing appeals and administrative burden on providers and payers.
Annual public reporting limited to denial percentages may not show which services or patient groups are most affected, reducing the immediate usefulness of the data for patients seeking targeted remedies.
Based on analysis of 2 sections of legislative text.
Insurers must notify individuals about medical-necessity denials with standards and reasons, and annually report plan denial rates to the Secretary.
Official title: To amend title XXVII of the Public Health Service Act to establish civil liability for health insurance issuers with high levels of claims denials.
Introduced April 22, 2026 by Angela Craig · Last progress April 22, 2026
Requires health insurance plans (group and individual) to send patients a clear, individual notice when a claim is denied as not medically necessary that includes the insurer's medical necessity standards and an explanation of why the service did not meet them. Requires issuers to submit annually to the federal Secretary the percentage of claims denied under each covered plan for any reason for each plan year. The requirements apply to plan years beginning on or after January 1, 2027, and add the new rules into the Public Health Service Act. The goal is greater transparency about denial policies and denial rates so consumers and regulators can better understand insurer decision-making.