Medicare Advantage Improvement Act of 2026
- Sponsor
- Rep. Joyce, John [R-PA-13]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Apr 27, 2026
Bottom line
The bill aims to enhance beneficiary access to timely care and increase accountability for Medicare Advantage organizations by streamlining authorization processes, standardizing coverage rules, and bolstering oversight.
What it actually does
This bill proposes significant reforms to the Medicare Advantage (MA) program by reducing timeframes for prior authorization decisions, establishing a real-time authorization process for certain services, and aligning MA medical necessity criteria with traditional Medicare. It also introduces a compliance scoring program for MA organizations with potential payment reductions for non-compliance, and strengthens guardrails against retrospective denials and clawbacks.
Proponents argue
Supporters argue that the bill will significantly improve the beneficiary experience by ensuring timely access to medically necessary care, reducing administrative burdens on healthcare providers, and increasing transparency and fairness in Medicare Advantage plans. They contend these reforms are essential to protect seniors from unnecessary delays and denials of care.
Opponents contend
Opponents may argue that the proposed reforms could impose substantial new compliance costs on Medicare Advantage organizations, potentially leading to higher premiums, reduced supplemental benefits, or a decrease in plan offerings. They might also contend that limiting prior authorization flexibility could hinder MA plans' ability to manage care effectively and control healthcare utilization.
The bill is moderately complex due to its technical amendments to the Social Security Act, but its structure allows an informed reader to understand its core provisions within a reasonable timeframe.
Section 2(a)
Reduced Timeframes for Prior Authorization Decisions
This provision mandates that Medicare Advantage organizations must respond to standard prior authorization requests for 'specified authorizations' (including prior, preservice, concurrent determinations, and facility transfers) within 72 hours, down from the current 14 days, starting January 1, 2028. Expedited requests must be answered within 24 hours. It also requires MA plans to report prior authorization data at the plan and parent organization level, making it publicly available and downloadable for research.
Supporters argue
Supporters argue that these reduced timeframes are crucial for patient safety and timely access to care, preventing adverse health outcomes due to delays. They also contend that increased transparency will allow for better oversight and accountability of MA plans.
Critics contend
Opponents may argue that such aggressive timelines could strain MA organizations' resources, potentially leading to less thorough reviews or increased costs that are passed on to beneficiaries. They might also claim that the current timelines are sufficient for most cases.
Tradeoffs
The provision balances the need for timely patient care against the administrative and financial capacity of MA organizations to process requests and manage utilization effectively.
Section 2(b)
Real-Time Authorization for Identified Services
This section requires Medicare Advantage organizations, starting January 1, 2028, to implement mechanisms for real-time authorization decisions for specific items and services. These services will be identified annually by the Secretary based on criteria such as high approval rates, low clinical risk, or high administrative burden. Requests for these services must be submitted via certified EHR technology, and the system must provide immediate automated approvals and notifications.
Section 3(a)
MAO Compliance Scoring and Accountability Program
This section establishes a new program, effective January 1, 2028, to assess Medicare Advantage organizations' compliance with various MA program requirements, including timely authorizations, coverage criteria, and prompt payment. MAOs will receive a total compliance score, which will place them into one of four tiers. Organizations in lower compliance tiers (scores below 90) will face monthly payment reductions ranging from 1.0% to 2.0% of their payments. The compliance scores and assessments will be publicly disclosed.
Section 4(b)
Prohibition on Retrospective Denials for Authorized Services
This provision, effective January 1, 2028, prohibits Medicare Advantage organizations from retroactively denying coverage or changing claim codes to reduce payment for an item or service that was previously approved through a 'specified authorization' (especially concurrent determinations made during receipt of service). Exceptions are made only for 'good cause' or reliable evidence of fraud or similar fault, as defined by existing regulations.
Section 5(b)
Consistent Medical Necessity Criteria with Traditional Medicare
Beginning January 1, 2028, this provision prohibits Medicare Advantage organizations from applying medical necessity criteria that are more restrictive than the 'reasonable and necessary' standards used in traditional Medicare (Fee-for-Service, FFS). This applies to all determinations and reconsiderations, including specific criteria for inpatient rehabilitation facilities and long-term care hospitals. It also requires that medical necessity determinations be made by healthcare professionals with appropriate expertise.
Section 6(b)
Automated Review and Payment for Certain Claims
Effective January 1, 2028, this provision requires Medicare Advantage organizations to implement automated payment processes for claims related to authorized items/services or those on the real-time authorization list. These claims must be automatically processed and paid without manual review, except in cases where there is reasonable evidence of fraud. This aims to eliminate inefficiencies in administrative processing.
Grants the Secretary of Health and Human Services the authority, for requests made on or after January 1, 2030, to specify through notice and comment rulemaking a different deadline for authorization requests than the 72-hour or 24-hour deadlines established in the bill.
Section 2(a)(1)(C)(iv)
Why it matters:This is standard legislative practice to provide future regulatory flexibility, allowing the agency to adapt rules based on implementation experience without requiring new legislation.
Case for: Allows CMS to adjust authorization deadlines if the initial 2028 timelines prove unworkable or if technological advancements enable even faster processing, ensuring the program remains adaptable.
Case against: Critics might argue that this future authority could be used to roll back beneficiary protections or increase administrative burdens if a future Secretary decides to lengthen the deadlines, undermining the bill's intent.
Estimated impact: Potential for future adjustments to authorization timelines, impacting beneficiaries and MA plans. The immediate impact is minimal, but the long-term flexibility is significant.
Requires the Secretary to assign a weight to measures included under the new MA Program Compliance and Coverage Protection Domain in the Star Ratings system that is 'greater than the weight assigned to measures included under any other domain.'
Section 3(b)(2)(D)
Why it matters:While technically specific, the precise weighting of Star Ratings domains can be a highly impactful policy decision often placed in technical sections. Its placement here ensures it is part of the legislative text rather than left solely to regulation.
Case for: Supporters would argue that this ensures compliance and coverage protections are prioritized in the Star Ratings system, strongly incentivizing MA plans to adhere to the new rules and improve beneficiary experience, as Star Ratings directly impact bonus payments.
Case against: Opponents might contend that giving disproportionate weight to this domain could de-emphasize other important quality measures (e.g., clinical outcomes, patient experience) that are also crucial for comprehensive plan assessment, potentially distorting plan priorities.
Estimated impact: Significantly increases the financial and reputational stakes for MA organizations regarding compliance with the new authorization and coverage rules, as it will heavily influence their Star Ratings and associated bonus payments.
Specifies that the prohibition on retrospective denials for authorized services includes exceptions for 'good cause' (as described in sections 405.986 and 422.616 of title 42, Code of Federal Regulations) or 'reliable evidence of fraud or similar fault' (as defined in section 405.902 of such title).
Section 4(b)
Why it matters:This is a common legislative technique to incorporate existing regulatory frameworks by reference, avoiding the need to re-state complex definitions and ensuring consistency with established legal principles for Medicare program integrity.
Case for: Supporters would argue that these exceptions are essential to prevent abuse and protect the integrity of the Medicare program, ensuring that MA plans can still address genuine errors or fraudulent claims even after an initial authorization.
Case against: Critics might express concern that the 'good cause' exception, if interpreted broadly, could provide MA plans with loopholes to continue retrospective denials, undermining the bill's intent to provide payment certainty.
Estimated impact: These exceptions provide critical safeguards for MA plans to address fraud and significant errors, preventing the bill from creating an absolute prohibition on all post-authorization adjustments. The practical impact depends on how 'good cause' is interpreted.