Sponsors (2)
The bill standardizes and limits prior-authorizations for certain high-cost items in Medicare Advantage—speeding access and reducing paperwork for many beneficiaries and some providers—while risking higher plan costs/premiums, extra burden on smaller providers, and uneven access if plans retain stricter rules for certain clinicians.
Medicare beneficiaries will face fewer and more consistent prior-authorization hurdles for identified high-cost services and Part D drugs, speeding access to necessary care.
MA plans and providers will use standardized forms and policies for identified high-spend items, reducing paperwork variability and accelerating care decisions across plans.
Hospitals and clinicians participating in two-sided risk payment models can avoid standardized prior authorizations, lowering administrative burden and smoothing care coordination for those providers.
Taxpayers and middle-class families could face higher premiums or shifted costs if standardizing prior authorizations limits MA plans' ability to control spending.
Smaller practices and other providers not in two-sided risk arrangements may face increased administrative tasks from standardized prior authorizations, raising workload and compliance costs for those clinicians and systems.
Medicare beneficiaries could experience uneven access to streamlined prior authorizations because MA organizations can request that the exemption not apply, allowing plans to keep stricter requirements for some providers.
Based on analysis of 2 sections of legislative text.
Requires HHS to audit MA prior-authorization and then standardize PA rules and forms across Medicare Advantage plans for identified high-spend items, services, and Part D drugs.
Official title: Amend part C of title XVIII of the Social Security Act to provide for prior authorization reforms under the Medicare Advantage program.
Introduced February 3, 2026 by Sheldon Whitehouse · Last progress February 3, 2026
Creates a new requirement for the Department of Health and Human Services to audit Medicare Advantage prior-authorization practices and then standardize prior-authorization rules and forms for high-spend items, services, and Part D drugs across all Medicare Advantage plans. The bill also lets providers who participate in two-sided risk models (including certain ACOs) be exempt from the standardized prior authorization unless a plan asks otherwise. The audit must identify items/services and Part D drugs that meet three criteria (top 10% of MA reimbursements, enough clinical evidence to set a medical policy, and overly burdensome prior-authorization steps) by January 1, 2027; a final HHS rule standardizing prior-authorizations for those items must be issued by May 1, 2028.