Medicare Advantage Improvement Act

Summary#

This bill would change how Medicare Advantage (MA) plans handle prior authorizations, payment, coverage decisions, reporting, and oversight. Key changes start mostly January 1, 2028. MA plans would have shorter deadlines to respond to prior-authorization requests (generally within 72 hours) and shorter deadlines for expedited requests (generally 24 hours). The bill requires MA organizations to support real-time authorization decisions for certain low-risk or high-volume services when requests are submitted through certified electronic health record (EHR) systems. MA plans must report prior-authorization and real-time decision data at the plan and parent organization levels and make some data publicly downloadable. The bill would stop MA plans from requiring a new authorization when a provider makes a clinically necessary change or extension to an already-authorized service, though plans may require documentation or post-service notice.

The bill tightens reconsideration and review timelines, requires outside independent reviewers to follow specific notice and decision deadlines, and limits when third-party entities can perform medical-necessity reviews (for example, not for already-authorized services). It creates a compliance scoring program for MA organizations tied to payment reductions: organizations are scored 0–100 across several compliance categories (including timely authorizations, coverage criteria, prompt payment, marketing/enrollment rules, and claims handling). Based on the score, CMS would place MA organizations in one of four compliance tiers; lower tiers would face payment reductions (1.0%, 1.5%, or 2.0). The bill also adds a new MA Program Compliance and Coverage Protection Domain to the Star Ratings system and gives that domain greater weight than other domains.

Other provisions: it codifies the two-midnight inpatient presumption and requires MA medical-necessity decisions to use the same "reasonable and necessary" standards as fee-for-service Medicare. It extends prompt payment requirements to all claims for authorized services (both in- and out-of-network), prevents MA plans from denying coverage or changing claim codes for an item or service after it was authorized except for good cause or proven fraud, requires automated processing and payment for certain authorized claims, and adds network adequacy standards for long-term care hospitals and inpatient rehabilitation facilities.

What it means for you#

• If you are enrolled in a Medicare Advantage plan: you may get faster authorization decisions for many services, and an approval given while you are receiving care generally cannot later be denied for lack of medical necessity except for limited reasons. You should see more public information about prior-authorizations and plan compliance.
• If you are a health care provider or supplier: the bill pushes MA plans to accept electronic requests through certified EHRs, give real-time or faster decisions for many requests, and pay promptly for claims tied to authorized services. Providers may have clearer rules about when additional authorization is not required for clinically necessary changes.
• If you run or work for a Medicare Advantage organization: you would face new reporting requirements, faster authorization and reconsideration deadlines, limits on use of third-party reviewers for authorized services, and a public compliance score that can reduce monthly payments if your organization falls into lower compliance tiers.

Expenses#

• The bill specifies payment reductions for Medicare Advantage organizations in lower compliance tiers: 1.0 percent, 1.5 percent, or 2.0 percent of monthly payments depending on the tier. It also requires new reporting, auditing, and administrative activities by the Secretary and by MA organizations.
• No publicly available information on the bill's overall costs or savings to the federal government or on estimated implementation costs.

Proponents' View#

No publicly available information.

Opponents' View#

No publicly available information.