Sponsors (2)
The bill improves patient notice and appeals rights and creates oversight data on denial rates, but it increases administrative burdens and costs for insurers and providers and may produce public reports too aggregated to be fully actionable for affected patients.
Patients denied coverage — especially people with chronic conditions and uninsured individuals — will receive individualized notices explaining which medical-necessity standard was applied and why the specific service was denied, enabling clearer understanding and more effective appeals or second opinions.
Hospitals, health systems, and state governments (and ultimately regulators) will gain oversight data because insurers must report annual denial rates to the Secretary, creating a basis to identify excessive denial patterns and pursue policy or enforcement actions.
Insurers will incur additional administrative costs to produce individualized denial notices and annual reports, and those costs could be passed on to consumers as higher premiums or reduced benefits.
Detailed notices that disclose the issuer’s medical-necessity criteria and reasoning may provoke more disputes and appeals, increasing administrative burden on insurers, providers, and hospitals and straining clinical and administrative staff.
Patients (notably those with chronic conditions) may get limited benefit from the required public reporting because annual reports are limited to denial percentages and may not reveal which specific services or populations are most affected, reducing immediate usefulness for targeted remedies.
Based on analysis of 2 sections of legislative text.
Requires insurers to notify individuals when a claim is denied as not medically necessary with standards and reasons, and to annually report claim denial rates to HHS.
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 insurers who offer individual or group coverage to give a written notice to an individual when a claim is denied as "not medically necessary" that explains the issuer’s medical necessity standards and why the item or service failed to meet them. The bill also requires issuers to submit an annual report to the Secretary of Health and Human Services showing the percentage of claims denied under each plan for any reason. The rules apply to plan years beginning on or after January 1, 2027.