Protecting Approved Care Act
- Sponsor
- Rep. Landsman, Greg [D-OH-1]
- Committees
- Ways and Means Committee (primary)
- Last action
- Sep 15, 2026
Bottom line
The 'Protecting Approved Care Act' aims to reduce unexpected denials and payment reductions by Medicare Advantage plans for services already authorized or not requiring prior approval, thereby increasing payment certainty for providers and beneficiaries.
What it actually does
This bill amends the Social Security Act to prevent Medicare Advantage (MA) organizations from retroactively denying coverage or reducing payment for items and services that have already received a 'specified authorization,' such as a prior authorization or concurrent review. It also applies these protections to services for which no prior authorization was required, with exceptions for good cause or reliable evidence of fraud.
Proponents argue
Proponents argue this bill protects beneficiaries and providers from unexpected denials and payment clawbacks by MA plans, ensuring that care approved upfront or not requiring prior authorization is indeed covered. This improves patient access to care, reduces administrative burden, and mitigates financial risk for healthcare providers by guaranteeing payment for authorized services.
Opponents contend
Opponents might argue that these limitations could reduce MA plans' ability to effectively manage costs and prevent fraud, potentially leading to higher premiums or reduced benefits for enrollees. They may also contend that it removes a crucial tool for ensuring medical necessity and appropriate utilization of services, especially if initial authorizations are flawed.
The bill is very short and straightforward, allowing for a quick and comprehensive reading.
Section 2, amending Section 1857(e) of the Social Security Act (42 U.S.C. 1395e-27(e)) by adding new paragraph (7).
Limitations on Claims Denial for Covered Items and Services in Medicare Advantage
This provision mandates that starting January 1, 2028, Medicare Advantage plans cannot deny coverage based on lack of medical necessity, reopen coverage or payment determinations (including prior authorizations), or change claim codes to reduce payment for services that were either previously authorized ('specified authorization') or did not require prior authorization. Exceptions are made only for 'good cause' or 'reliable evidence of fraud or similar fault,' as defined in existing regulations.
Supporters argue
Supporters argue this provision directly addresses a significant problem where MA plans approve care upfront, only to deny it later, leaving patients with unexpected bills and providers with unpaid services. It ensures that an approval means a guarantee of coverage, fostering trust, streamlining care delivery, and reducing unnecessary administrative appeals.
Critics contend
Opponents might argue that this provision unduly restricts MA plans' ability to detect and correct errors, or to combat waste and abuse effectively. They may contend that the 'good cause' and 'fraud' exceptions are too narrow, potentially forcing plans to pay for services that were not medically necessary but received a flawed initial authorization, ultimately driving up costs.
Tradeoffs
The bill balances the desire for payment certainty and reduced administrative burden for providers and beneficiaries against the need for MA plans to manage costs, ensure medical necessity, and prevent fraud and abuse. It aims to shift more financial risk to MA plans for their initial authorization decisions, potentially impacting their operational flexibility.
Defines 'specified authorization' to include prior authorization, preservice determinations, concurrent determinations made while the individual is receiving the service, and authorizations for transfers between hospitals or to post-acute care facilities.
Section 2, new paragraph (7)(C).
Why it matters:This is standard legislative practice to define key terms within the bill to ensure clarity and precise application of the law.
Case for: Proponents would argue that a clear and broad definition of 'specified authorization' is essential to ensure comprehensive protection against retroactive denials, covering various stages of care approval and transfers, thereby closing potential loopholes.
Case against: Opponents might argue that a broad definition could inadvertently limit plans' ability to review and adjust claims even when new information emerges during concurrent care, beyond the specified 'good cause' or 'fraud' exceptions, potentially hindering effective utilization management.
Estimated impact: This definition ensures that the protections against claims denial apply broadly across the spectrum of pre-service and in-service approvals within MA plans, significantly impacting the types of services and situations covered by the new rules.