Sponsors (18)
The bill makes it easier and more predictable for Medicare beneficiaries and providers to get denials reconsidered, but it risks higher plan costs and more conservative initial denials that could raise enrollee costs or delay care.
Medicare beneficiaries will have coverage denials automatically reconsidered by plans, reducing the need for beneficiaries to request reviews and speeding access to final coverage decisions.
Hospitals, health systems, providers, families, and patients (especially those with chronic conditions) will face fewer administrative steps and greater predictability because plans must initiate reconsideration and base timing on the date of the adverse determination.
Patients with chronic conditions and Medicare beneficiaries may experience slower access to needed care because plans could issue more conservative initial coverage denials to manage increased reconsideration workload, potentially delaying approvals.
Medicare Advantage enrollees may face higher premiums, reduced benefits, or narrower networks if plans incur higher administrative costs from mandatory reconsiderations and shift those costs to enrollees.
Based on analysis of 2 sections of legislative text.
Requires Medicare Advantage plans to automatically reconsider denials of coverage and ties notice timing to the date the adverse determination is made.
Introduced November 18, 2025 by Mark Pocan · Last progress November 18, 2025
Requires Medicare Advantage organizations to automatically reconsider any adverse coverage determination that denies a benefit instead of waiting for the enrollee to request reconsideration. It also changes the timing for required notice so that notices are tied to the date the adverse determination was made rather than to the date an enrollee’s request for reconsideration is received. No new funding or other program changes are specified.