Stop Deadly Denials Act of 2026
- Sponsor
- Rep. Khanna, Ro [D-CA-17]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Apr 20, 2026
Bottom line
The bill aims to significantly reduce administrative burdens and potential care delays for Medicare beneficiaries by largely eliminating prior authorization in Medicare Advantage and limiting its expansion in traditional Medicare.
What it actually does
This bill primarily prohibits Medicare Advantage plans from imposing prior authorization requirements for most specified items and services, effective January 1, 2027. It also restricts the Center for Medicare and Medicaid Innovation (CMI) from implementing new payment models that test prior authorization under traditional Medicare, especially those using artificial intelligence for denials without physician review or not processed by Medicare administrative contractors. Furthermore, it mandates public notice and comment for all future CMI models.
Proponents argue
Supporters argue that prior authorization often leads to delays in medically necessary care, unnecessary denials, and adverse health outcomes for seniors, particularly within Medicare Advantage plans. They contend that this legislation would ensure timely access to essential services, reduce administrative burdens on healthcare providers, and increase transparency in Medicare innovation models.
Opponents contend
Opponents might argue that prior authorization is a crucial tool for controlling healthcare costs, preventing fraud and abuse, and ensuring the appropriate utilization of services. They may contend that eliminating it could lead to increased healthcare spending, potentially higher premiums for beneficiaries, and a reduction in the ability of Medicare Advantage plans to manage care effectively.
The bill is concise and relatively straightforward for those familiar with Medicare terminology, making it accessible for a quick but informed review.
Section 2(a), amending Section 1852 of the Social Security Act
Prohibition of Prior Authorization Requirements in Medicare Advantage Plans
This provision mandates that, starting January 1, 2027, Medicare Advantage (MA) plans cannot require prior authorization for most healthcare services. This prohibition applies to 'specified items or services,' which include most medical services but exclude covered Part D prescription drugs and supplemental health benefits offered by MA plans. An exception is made for services that are already subject to prior authorization under specific provisions of traditional Medicare (Parts A or B).
Supporters argue
Supporters argue that this prohibition will protect beneficiaries from harmful delays and denials of care, ensuring they receive timely access to necessary medical services without undue administrative interference from their insurance plans.
Critics contend
Opponents contend that removing prior authorization will eliminate a crucial mechanism for controlling costs, preventing fraud, and ensuring that services are medically appropriate, potentially leading to increased healthcare spending and higher premiums.
Tradeoffs
The provision navigates the tension between ensuring patient access to care and allowing health plans to manage costs and utilization. It prioritizes patient access and provider administrative relief over the cost-containment strategies of MA plans.
Section 2(b), amending Section 1857(g)(1) of the Social Security Act
Intermediate Sanctions for Medicare Advantage Prior Authorization Violations
This section amends existing law to allow the Secretary of Health and Human Services to impose intermediate sanctions on Medicare Advantage organizations that violate the new prohibition on prior authorization. This means if an MA plan improperly requires prior authorization for a specified item or service, it could face penalties such as civil monetary penalties or suspension of enrollment.
Section 3(a) and 3(b), amending Section 1115A(b)(2) of the Social Security Act
Restrictions on Prior Authorization in Traditional Medicare Innovation Models
This provision prohibits the Secretary of Health and Human Services from implementing the 'Wasteful and Inappropriate Services Reduction (WISeR) Model' or any similar model that tests prior authorization. Furthermore, it generally restricts the Center for Medicare and Medicaid Innovation (CMI) from selecting any new models that would implement prior authorization in traditional Medicare if those models use artificial intelligence, machine learning, or algorithmic logic for coverage denials without individual physician review and approval, or if prior authorization requests are processed by entities other than Medicare administrative contractors.
Section 3(c), amending Section 1115A(b)(2)(A) of the Social Security Act
Public Notice and Comment Requirement for Future CMI Models
This provision mandates that, beginning January 1, 2027, any new innovative payment and service delivery model selected by the Center for Medicare and Medicaid Innovation (CMI) must first undergo a public notice and opportunity for public comment process. This ensures that stakeholders and the public have a formal chance to provide input before new models are implemented.
The prohibition on prior authorization in Medicare Advantage plans does not apply to items or services that are already subject to prior authorization under specific, existing provisions of traditional Medicare (Parts A or B). This means if traditional Medicare already requires prior authorization for a particular service, MA plans can continue to require it for that service.
Section 1852(o)(2) of the Social Security Act, as added by Section 2(a) of the bill.
Why it matters:This is standard legislative practice to define the precise scope and limitations of a new rule, ensuring consistency with existing law where deemed appropriate.
Case for: Supporters would argue that this exception prevents creating a two-tiered system where MA plans are more restrictive than traditional Medicare for services already deemed to require prior authorization. It maintains existing safeguards where they are already in place.
Case against: Critics might contend that this exception creates a loophole, allowing MA plans to continue using prior authorization for a subset of services, thereby not fully achieving the bill's stated goal of eliminating 'deadly denials' across the board. It could lead to confusion for beneficiaries about which services are still subject to prior authorization.
Estimated impact: This provision narrows the scope of the Medicare Advantage prior authorization ban, meaning that a limited set of services that already have prior authorization in traditional Medicare will remain subject to it in MA plans. The precise impact depends on the volume of services covered by the referenced sections.