No Medicare Clawbacks Act of 2026
- Sponsor
- Rep. Torres, Ritchie [D-NY-15]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Jun 29, 2026
Bottom line
The bill protects Medicare beneficiaries with retroactive Part A coverage from unexpected financial demands by their group health plans for services already paid.
What it actually does
This bill amends the Social Security Act to prevent group health plans from recouping payments from individuals in specific situations. Specifically, if a group health plan initially pays for a service for an individual who is later found to have retroactive Medicare Part A coverage, the plan cannot claw back that payment from the individual. This protection applies only if the individual was not behind on their employee contributions to the group health plan at the time the service was furnished.
Proponents argue
Supporters argue this bill provides crucial financial protection for beneficiaries, particularly those who may be unaware of their retroactive Medicare eligibility, preventing them from being caught in complex payment disputes between their health plan and Medicare. It aims to reduce administrative burdens and unexpected out-of-pocket costs for vulnerable individuals.
Opponents contend
Critics might contend that this bill could shift financial burdens onto group health plans, potentially leading to increased costs for employers and higher premiums for all plan enrollees. They may argue it could create disincentives for individuals to promptly report Medicare eligibility, complicating coordination of benefits and potentially increasing costs for private insurers.
The bill is very short and clear, making it highly accessible for a reader to understand its core provisions quickly.
Section 2, Paragraph (1)(B), Subclause (II)
Prohibition on Group Health Plan Payment Clawbacks
This provision prevents a group health plan from taking back payments it made for healthcare services from an individual. This applies if the individual was entitled to Medicare benefits (specifically under section 226(a), typically for age or disability) and the plan initially paid without knowing about the Medicare entitlement. The prohibition is active only if the service was provided during a period when the individual had retroactive Medicare Part A coverage and was current on their group health plan contributions.
Supporters argue
Supporters argue this provision safeguards beneficiaries from unexpected and often substantial bills, ensuring that individuals are not penalized for the complexities of Medicare's secondary payer rules or delays in eligibility determination. It provides financial certainty and reduces stress for those navigating healthcare costs.
Critics contend
Opponents might argue that this provision places an undue financial burden on group health plans, forcing them to cover costs that Medicare should ultimately bear as the primary payer. This could lead to increased operational costs for plans, which may be passed on to employers and employees through higher premiums or reduced benefits.
Tradeoffs
The provision balances the protection of beneficiaries from unexpected costs against the financial responsibilities and administrative complexities for group health plans. It aims to resolve payment ambiguities in favor of the individual, potentially at the expense of private insurers' ability to recover funds.
Section 2, Paragraph (2)
Enforcement Mechanism for Clawback Prohibition
This provision amends existing law to clarify that if a group health plan violates the new prohibition on payment clawbacks, the government can take action to recover those improperly recouped payments. This ensures that the new protection for beneficiaries is enforceable and provides a mechanism for the Centers for Medicare & Medicaid Services (CMS) to intervene if plans attempt to claw back payments in violation of the Act.