Sponsors (19)
The bill strengthens CMS enforcement to reduce inappropriate prior-authorizations and improve beneficiary access, but risks mid-year plan disruptions, market responses that could limit choice or raise costs, and adds enforcement costs.
Medicare beneficiaries will likely face fewer inappropriate prior-authorization denials, improving access to covered services.
Strengthens CMS's ability to hold Medicare Advantage (MA) plans accountable by allowing termination of contracts with persistently high reversal rates, increasing regulatory oversight and enforcement.
Hospitals, clinicians, and patients may experience reduced administrative burden and fewer treatment delays if MA plans improve prior-authorization decisions to avoid termination.
Medicare Advantage enrollees could lose their plan mid-year if a carrier's contract is terminated, forcing plan changes and potential network or provider disruptions.
MA organizations may respond to the threat of termination by narrowing benefits, changing prior-authorization practices, or exiting markets, which could reduce plan choices or raise premiums for beneficiaries and stress provider networks.
CMS will incur additional monitoring and enforcement costs to track reversal rates and assess causation for year-over-year drops, which could divert agency resources or increase administrative spending.
Based on analysis of 2 sections of legislative text.
Requires termination of Medicare Advantage contracts if a plan’s prior-authorization denials are later reversed above set thresholds or if the plan fails to properly reconsider denials.
Requires Medicare Advantage (MA) contracts to be terminated if the plan’s prior-authorization (PA) coverage determinations show unacceptably high reversal rates or if the plan fails to appropriately reconsider denials, starting for plan years that begin one year after the law is enacted. It also defines what counts as a “prior authorization coverage determination.” This creates a measurable enforcement trigger for the Secretary of Health and Human Services to remove MA plans that systematically deny care later found appropriate on reconsideration or appeal.
Introduced November 18, 2025 by Mark Pocan · Last progress November 18, 2025