H.R. 8375

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8375 Introduced in House (IH)]

<DOC>

119th CONGRESS
2d Session
H. R. 8375

To amend title XVIII of the Social Security Act to provide for certain 
reforms under the Medicare Advantage program, and for other purposes.

_______________________________________________________________________

IN THE HOUSE OF REPRESENTATIVES

April 20, 2026

Mr. Joyce of Pennsylvania (for himself, Ms. Schrier, Mr. Murphy, Mr. 
Panetta, Mrs. Miller-Meeks, Mr. Bera, and Ms. Van Duyne) introduced the 
following bill; which was referred to the Committee on Ways and Means, 
and in addition to the Committee on Energy and Commerce, for a period 
to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
committee concerned

_______________________________________________________________________

A BILL

To amend title XVIII of the Social Security Act to provide for certain 
reforms under the Medicare Advantage program, and for other purposes.

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``Medicare Advantage Improvement Act 
of 2026''.

SEC. 2. IMPROVING ACCESS TO TIMELY CARE FOR ENROLLEES OF MEDICARE 
ADVANTAGE PLANS.

(a) Reducing Timeframes for Medicare Advantage Organizations To 
Respond to Certain Authorization Requests.--
(1) Standard organization determinations.--Section 
1852(g)(1) of the Social Security Act (42 U.S.C. 1395w-
22(g)(1)) is amended--
(A) in subparagraph (A), in the second sentence, by 
inserting ``subparagraph (C) and'' after ``Subject 
to'';
(B) in subparagraph (B), by striking ``Such a 
determination'' and inserting ``A determination 
described in subparagraph (A) or (C)''; and
(C) by adding at the end the following new 
subparagraph:
``(C) Required timeframes for responses to certain 
authorization requests.--
``(i) In general.--Subject to clause (ii) 
and paragraph (3)(B)(iii), the procedure 
established pursuant to subparagraph (A) by a 
Medicare Advantage organization offering an MA 
plan shall provide that in the case of a 
request made on or after January 1, 2028, for a 
specified authorization (as defined in clause 
(iii)) with respect to an individual enrolled 
under such plan, the Medicare Advantage 
organization must notify the individual (and 
the provider of services or supplier involved, 
as appropriate) of the determination regarding 
such request as expeditiously as the health 
condition of the individual requires, but, 
subject to clause (iv), not later than 72 hours 
after receipt of the request.
``(ii) Extensions.--Subject to clause (iv), 
a Medicare Advantage organization offering an 
MA plan may extend the deadline applied under 
clause (i) or the deadline applied under 
paragraph (3)(B)(iii)(II), as applicable, with 
respect to a determination regarding a 
specified request for an individual enrolled 
under the MA plan, by up to 7 calendar days 
if--
``(I) the individual requests the 
extension;
``(II) the extension is needed for 
purposes of obtaining additional 
relevant medical evidence from a 
provider of services or supplier that 
does not have a contract with the MA 
organization to furnish items and 
services to individuals enrolled under 
the MA plan; or
``(III) the extension is in the 
individual's interest and is justified 
by reason of extraordinary, exigent, or 
other nonroutine circumstances that are 
not within the reasonable control of 
the MA organization (as determined by 
the Secretary).
``(iii) Specified authorization defined.--
For purposes of this part, the term `specified 
authorization'--
``(I) means, with respect to an 
individual enrolled under an MA plan 
offered by a Medicare Advantage 
organization, an authorization of 
coverage or payment for an item or 
service through--
``(aa) a prior 
authorization or preservice 
determination of coverage or 
payment; or
``(bb) a concurrent 
determination made while the 
individual is receiving the 
relevant item or service; and
``(II) includes an authorization 
for a transfer of the individual 
between hospitals or between a hospital 
and post-acute care facility.
``(iv) Secretarial authority.--With respect 
to requests for a specified authorization made 
on or after January 1, 2030, in carrying out 
clause (i) and (ii) and paragraph 
(3)(B)(iii)(II), the Secretary may specify 
through notice and comment rulemaking a 
deadline other than the deadline specified in 
the relevant clause or paragraph.''.
(2) Expedited organization determinations.--Section 
1852(g)(3)(B)(iii) of the Social Security Act (42 U.S.C. 1395w-
22(g)(3)(B)(iii)) is amended--
(A) by striking ``Timely response.--In cases 
described'' and inserting: ``Timely reponse.--
``(I) In general.--Subject to 
subclause (II), in cases described''; 
and
(B) by adding at the end the following new 
subclause:
``(II) Reducing expedited 
timeframes for responses to certain 
authorization requests.--Subject to 
paragraph (1)(C)(ii), in cases 
described in clauses (i) and (ii) that 
are related to an expedited 
determination for a specified 
authorization (as defined in paragraph 
(1)(C)(iii)) for which a request is 
submitted on or after January 1, 2028, 
the Medicare Advantage organization 
shall notify the enrollee (and the 
physician involved, as appropriate) of 
the determination under time 
limitations established by the 
Secretary. Subject to paragraph 
(1)(C)(iv), such notification shall be 
made not later than 24 hours after the 
receipt of the request for the 
determination (or receipt of the 
information necessary to make the 
determination).''.
(3) Improved transparency of certain prior authorization 
information on the ma plan level.--Beginning with plan years 
beginning on or after January 1, 2028, in carrying out the 
provisions of section 422.122(c) of title 42, Code of Federal 
Regulations (or any successor regulation), the Secretary of 
Health and Human Services shall--
(A) require Medicare Advantage organizations to 
report prior authorization data described in such 
section on the plan level and on the Medicare Advantage 
organization parent level in addition to the contract 
level;
(B) require Medicare Advantage organizations to 
report prior authorization data described in such 
section in a manner that allows comparison of such data 
based on provider and service category; and
(C) in addition to making such data publicly 
available, as described in such section, make such data 
available in a downloadable format that is accessible 
for research purposes and oversight and enforcement 
activities of the Secretary.
(b) Real-Time Authorization Decisions for Certain Identified 
Services.--Section 1852(g)(1) of the Social Security Act (42 U.S.C. 
1395w-22(g)(1)), as amended by subsection (a), is further amended--
(1) in subparagraph (A), in the second sentence, by 
striking ``subparagraph (C) and'' and inserting ``subparagraphs 
(C) and (D) and'';
(2) in subparagraph (B), by striking ``A determination 
described in subparagraph (A) or (C)'' and inserting ``A 
determination described in subparagraph (A), (C), or (D)'';
(3) in subparagraph (C)(i), by striking ``Subject to clause 
(ii)'' and inserting ``Subject to clause (ii), subparagraph 
(D),''; and
(4) by adding at the end the following new subparagraph:
``(D) Real-time authorization decisions for 
identified services.--
``(i) In general.--The procedure 
established pursuant to subparagraph (A) shall 
require that the Medicare Advantage 
organization has in place a mechanism and 
process through which, beginning January 1, 
2028, the organization provides a real-time 
determination, in accordance with this 
subparagraph, in response to any request for a 
specified authorization (as defined in 
subparagraph (C)(iii)) that is--
``(I) made with respect to an item 
or service identified on the most 
recent list published pursuant to 
clause (iii); and
``(II) submitted through certified 
EHR technology (as defined in section 
1848(o)(4)).
``(ii) Requirements for real-time mechanism 
and process.--The mechanism and process 
required under clause (i) shall--
``(I) include real-time tools 
capable of providing immediate 
automated approvals;
``(II) provide for the integration 
of such tools in a manner that is 
interoperable with certified EHR 
technology (as so defined) used by 
providers of services and suppliers; 
and
``(III) enable immediate 
notification to the provider of 
services or supplier, as applicable, of 
determinations, including, in the case 
of a denial, notification of any 
additional documentation needed.
``(iii) Annual publication of list of 
identified services requiring real-time 
authorization support.--For purposes of this 
subparagraph, for each plan year beginning on 
or after January 1, 2028, the Secretary shall 
annually establish through notice and comment 
rulemaking a list identifying the following 
items and services:
``(I) Items and services for which, 
with respect to the previous plan year, 
at least 90 percent of requests for a 
specified authorization were approved 
across all Medicare Advantage 
organizations.
``(II) Items and services that are 
clinically low-risk and routine, as 
defined by the Secretary through notice 
and comment rulemaking.
``(III) Items and services that the 
Secretary identifies, according to 
standards specified by the Secretary 
through notice and comment rulemaking, 
as representative of significant 
service volume and administrative 
burden for acquiring such a specified 
authorization.
``(iv) Improving transparency.--
``(I) Quarterly mao reports to 
cms.--Beginning January 1, 2028, and 
quarterly thereafter, each Medicare 
Advantage organization offering an MA 
plan shall submit to the Secretary (in 
a form and manner specified by the 
Secretary) information (presented by 
provider and service type) regarding 
real-time determinations made by the 
organization during the previous 
quarter pursuant to this subparagraph, 
including information on--
``(aa) the number of real-
time determinations made during 
the quarter, and the percentage 
of all determinations made 
during the quarter with respect 
to an item or service 
identified on the most recent 
list published pursuant to 
clause (iii) that were real-
time determinations;
``(bb) the number and 
percentage of real-time 
determinations made during such 
quarter that were approved;
``(cc) the number and 
percentage of such 
determinations that were 
denied;
``(dd) the number and 
percentage of such denied 
determinations that were 
appealed;
``(ee) the number and 
percentage of such appealed 
determinations that were 
overturned; and
``(ff) the number and 
percentage of provider 
complaints regarding the 
mechanism and process 
implemented by the Medicare 
Advantage organization pursuant 
to this subparagraph.
The information submitted pursuant to 
the previous sentence shall include 
such information and be provided in 
such a manner to enable comparison and 
analysis of such information on the 
Medicare Advantage organization level, 
Medicare Advantage parent organization 
level, and MA plan level.
``(II) Public availability of 
information.--The Secretary shall make 
information collected under subclause 
(I) publicly available on the internet 
website of the Centers for Medicare & 
Medicaid Services.''.
(c) Prohibiting Certain Authorization Processes for Certain 
Clinically Necessary Changes and Extensions.--Section 1852(d) of the 
Social Security Act (42 U.S.C. 1395w-22(d)) is amended by adding at the 
end the following new paragraph:
``(7) Prohibition on requiring certain authorizations.--
Beginning January 1, 2028, in the case that a Medicare 
Advantage organization offering an MA plan provides approval 
through a specified authorization (as defined in subsection 
(g)(1)(C)(iii)) for an item or service to be furnished to an 
individual enrolled in the plan by a provider of services or 
supplier, if during the course of furnishing such approved item 
or service the provider of services or supplier determines that 
a modification, extension, or adjustment to such item or 
service is clinically necessary, the Medicare Advantage 
organization may not require a specified authorization (as 
defined in subsection (g)(1)(C)(iii)) to be requested with 
respect to such item or service as so modified, extended, or 
adjusted. Application of the previous sentence shall not limit 
the authority of the Medicare Advantage organization to require 
documentation or post-service notification of any such 
modification, extension, or adjustment.''.
(d) Improvements to the Reconsiderations Process.--Section 1852(g) 
of the Social Security Act (42 U.S.C. 1395w-22(g)) is amended--
(1) in paragraph (2)--
(A) in subparagraph (A), by inserting ``(or, with 
respect to determinations made on or after January 1, 
2028, not later than 14 days)'' after ``60 days''; and
(B) by adding at the end the following new 
subparagraph:
``(C) Reconsiderations affirming denials of 
coverage.--If a reconsideration affirms (in whole or in 
part) a denial of coverage (including an adverse 
organization determination under section 422.590 of 
title 42, Code of Federal Regulations, or any successor 
regulation) made on or after January 1, 2028, with 
respect to an individual enrolled in an MA plan offered 
by a Medicare Advantage organization, the Medicare 
Advantage organization shall submit to the independent, 
outside entity with a contract under paragraph (4) the 
case file and written explanation of the decision as 
expeditiously as the individual's health condition 
requires, but not later than 14 days after the date the 
Medicare Advantage organization received the request 
for the reconsideration.''; and
(2) in paragraph (4)--
(A) by striking ``coverage denials.--The Secretary 
shall contract with'' and inserting: ``coverage 
denials.--
``(A) In general.--The Secretary shall contract 
with''; and
(B) by adding at the end the following new 
subparagraphs:
``(B) Requirements.--In reviewing and resolving 
pursuant to subparagraph (A) a reconsideration of a 
determination of a Medicare Advantage organization made 
on or after January 1, 2028, with respect to an 
individual enrolled in an MA plan offered by the 
organization, the independent, outside entity shall 
comply with each of the following requirements:
``(i) Notice and opportunity to provide 
supporting documentation.--The entity shall--
``(I) not later than 3 days after 
the date of receipt of the relevant 
case file from the Medicare Advantage 
organization, submit to the individual, 
the representative of the individual 
(if applicable), and the provider of 
services or supplier furnishing (or 
ordering) the item or service that is 
the subject of the determination, a 
notification regarding the opportunity 
to submit documentation, including 
medical records, regarding medical 
necessity; and
``(II) provide a period of 7 days 
from the date of receipt of such 
notification for submission of any such 
documentation.
``(ii) Decision timeframe.--After reviewing 
and considering all supporting documentation 
received before the end of the 7-day period 
described in clause (i)(II), the entity shall 
issue its decision with respect to such 
reconsideration as expeditiously as the 
individual's health condition requires, but by 
not later than the applicable number of days 
specified in subparagraph (C) after the last 
day of the 7-day period described in clause 
(i)(II).
``(C) Applicable number of days.--For purposes of 
subparagraph (B)(ii), the applicable number of days 
specified in this subparagraph is--
``(i) 14 days, in the case of a request 
(other than with respect to an expedited 
reconsideration under paragraph (3)) for 
coverage of an item or service that is not a 
drug for which payment may be made under part 
B;
``(ii) 7 days, in the case of a request 
(other than with respect to an expedited 
reconsideration under paragraph (3)) for 
coverage of a drug for which payment may be 
made under part B;
``(iii) 30 days, in the case of a request 
(other than with respect to an expedited 
reconsideration under paragraph (3)) for 
payment of an item or service; and
``(iv) 24 hours, in the case of a request 
with respect to an expedited reconsideration 
under paragraph (3).''.

SEC. 3. ENSURING APPROPRIATE OVERSIGHT OF MEDICARE ADVANTAGE PLANS.

(a) MAO Compliance Scoring and Accountability Program.--Section 
1853 of the Social Security Act (42 U.S.C. 1395w-23) is amended by 
adding at the end the following new subsection:
``(p) Compliance Scoring and Enforcement.--
``(1) Payment reductions for maos in noncompliance with 
certain ma program requirements.--
``(A) In general.--In the case of a Medicare 
Advantage organization with a contract under this part 
that the Secretary determines, in accordance with this 
subsection, to be within a compliance tier specified in 
subparagraph (B) for a performance period with respect 
to a plan year beginning on or after January 1, 2028, 
the Secretary shall reduce the total of the monthly 
payments made for the plan year under section 
1853(a)(1) to the Medicare Advantage organization with 
respect to each Medicare Advantage plan offered by such 
organization by the applicable percent specified under 
subparagraph (B) with respect to the compliance tier.
``(B) Applicable percent specified.--For purposes 
of subparagraph (A), the applicable percent specified 
under this subparagraph is as follows:
``(i) With respect to the compliance tier 
described in paragraph (5)(B), 1.0 percent.
``(ii) With respect to the compliance tier 
described in paragraph (5)(C), 1.5 percent.
``(iii) With respect to the compliance tier 
described in paragraph (5)(D), 2.0 percent.
``(C) Performance period.--For purposes of this 
subsection, the Secretary shall establish a performance 
period (or periods) for each plan year beginning on or 
after January 1, 2028. Such performance period (or 
periods) shall begin and end prior to the beginning of 
the plan year and be as close as possible to such plan 
year. In this subsection, such performance period (or 
periods) for a plan year shall be referred to as the 
performance period with respect to the plan year.
``(2) Establishment of compliance scoring and 
accountability program.--For purposes of this subsection, the 
Secretary shall establish a Medicare Advantage organization 
compliance scoring and accountability program (referred to 
under this subsection as the `MAO Compliance Program') under 
which, for each Medicare Advantage organization with a contract 
under this part and each performance period with respect to a 
plan year beginning on or after January 1, 2028, the 
Secretary--
``(A) using the method established under paragraph 
(3)(A), shall assess the extent to which the Medicare 
Advantage organization is in compliance with 
requirements under this part applicable to each 
compliance category specified under paragraph (3)(B);
``(B) based on such assessments for each such 
compliance category, shall assign a total compliance 
score to the Medicare Advantage organization, in 
accordance with paragraph (4); and
``(C) based on such total compliance score, shall 
assign the Medicare Advantage organization to a 
compliance tier described in paragraph (5).
``(3) Assessment method.--
``(A) In general.--Under the MAO Compliance 
Program, the Secretary shall establish through notice 
and comment rulemaking a method to assess, at the plan 
level, the extent to which each Medicare Advantage 
organization offering a Medicare Advantage plan is in 
compliance with requirements under this part applicable 
to each compliance category specified in subparagraph 
(B). Such method shall include the use of audit 
mechanisms, reporting requirements, performance 
measures established or identified by the Secretary 
(such as applicable measures under the MA Program 
Compliance and Coverage Protection Domain described in 
section 1853(o)(8)), and such other methods as 
specified by the Secretary.
``(B) Compliance categories.--
``(i) In general.--Subject to clause (ii), 
under the MAO Compliance Program, each of the 
following shall be a compliance category:
``(I) Compliance with timely and 
real-time specified authorization 
decision-making requirements, including 
compliance with section 1852(d)(7) and 
paragraphs (1)(C), (1)(D), and 
(3)(B)(iii)(II) of section 1852(g).
``(II) Compliance with coverage 
criteria standards, including the 
requirements under section 1852(g)(7) 
and section 1852(a)(2)(D).
``(III) Compliance with prompt 
payment requirements, including 
compliance with section 1857(f).
``(IV) Compliance with restrictions 
regarding improper retroactive denials 
and downgrades, including compliance 
with section 1852(g)(6) and section 
1857(e)(6).
``(V) Compliance with marketing, 
enrollment, and beneficiary 
communication requirements, including 
subpart V of part 422 of title 42, Code 
of Federal Regulations, or any 
successor to such regulations.
``(VI) Compliance with other 
requirements under this part, including 
section 1852(g)(1)(E) and such other 
requirements as specified by the 
Secretary.
``(ii) Updates.--The Secretary may, through 
notice and comment rulemaking, revise the 
compliance categories described in clause (i), 
including by specifying additional categories, 
removing categories, and otherwise updating the 
requirements that are included in any of such 
compliance categories.
``(4) Scoring methodology.--Under the MAO Compliance 
Program, the Secretary shall, through notice and comment 
rulemaking, establish a methodology to assign a total 
compliance score (using a scoring scale of 0 to 100) to each 
Medicare Advantage organization for the performance period with 
respect to a plan year. Such total compliance score shall be 
based on the assessment under paragraph (3) of plan-level 
compliance with respect to each compliance category described 
in subparagraph (B) of such paragraph, with each such category 
receiving equal weight (and, in the case of a Medicare 
Advantage organization offering more than one plan during the 
performance period, with each such assessment weighted by the 
number of individuals enrolled under such plan during such 
period).
``(5) Compliance tiers.--For each plan year beginning on or 
after January 1, 2028, the Secretary shall, based on the total 
compliance score assigned pursuant to paragraph (4) to a 
Medicare Advantage organization for the performance period with 
respect to such year, assign such Medicare Advantage 
organization to one of the following compliance tiers, as 
follows:
``(A) Compliance tier one, consisting of Medicare 
Advantage organizations receiving a total score for the 
performance period of at least 90.
``(B) Compliance tier two, consisting of Medicare 
Advantage organizations receiving a total score for the 
performance period of at least 75 but not more than 89.
``(C) Compliance tier three, consisting of Medicare 
Advantage organizations receiving a total score for the 
performance period of at least 60 but not more than 74.
``(D) Compliance tier four, consisting of Medicare 
Advantage organizations receiving a total score for the 
performance period of less than 60.
``(6) Review.--The Secretary shall establish a process 
under which a Medicare Advantage organization may seek a review 
of the total compliance score assigned to the organization 
pursuant to paragraph (4) for a performance period.
``(7) Public disclosures.--
``(A) In general.--For each plan year beginning on 
or after January 1, 2028, the Secretary shall make 
available on a public website of the Centers for 
Medicare & Medicaid Services and in an easily 
understandable format, information regarding the 
assessments under the MAO Compliance Program of 
compliance during the performance period with respect 
to the plan year by Medicare Advantage organizations, 
on the plan level, with requirements applicable to each 
compliance category specified in paragraph (3)(B). Such 
information shall include the total compliance score 
received by each Medicare Advantage organization 
pursuant to paragraph (4) for the performance period.
``(B) Opportunity to review and submit 
corrections.--The Secretary shall provide for an 
opportunity for a Medicare Advantage organization to 
review and submit corrections for the information to be 
made available under subparagraph (A) with respect to 
such organization prior to such information being made 
public.''.
(b) Expanding the MA Star Ratings Program To Include an MA Program 
Compliance and Coverage Protection Domain.--
(1) Data collection.--Section 1852(e)(3) of the Social 
Security Act (1395w-22(e)(3)) is amended--
(A) in subparagraph (A)(i), in the first sentence 
by inserting ``, including, for plan years beginning on 
or after January 1, 2028, with respect to measures 
under the MA Program Compliance and Coverage Protection 
Domain described in section 1853(o)(8)'' after ``other 
indices of quality''; and
(B) in subparagraph (B)(i), by inserting ``, and 
other than the types of data authorized under 
subparagraph (C) of section 1853(o)(8) for purposes of 
the MA Program Compliance and Coverage Protection 
Domain described in such section'' after ``as of 
November 1, 2003''.
(2) Addition of ma program compliance and coverage 
protection domain to ma star ratings system.--Section 1853(o) 
of the Social Security Act (1395w-23(o)) is amended by adding 
at the end the following new paragraph:
``(8) MA program compliance and coverage protection 
domain.--
``(A) In general.--For plan years beginning on or 
after January 1, 2028, in addition to any other domain 
under the 5-star rating system under paragraph (4)(A) 
used for determining star ratings of Medicare Advantage 
plans, the Secretary shall include under such system an 
MA Program Compliance and Coverage Protection Domain.
``(B) Measures.--Such domain shall include measures 
to assess compliance of each Medicare Advantage plan 
with each of the compliance categories specified in 
section 1853(p)(3)(B).
``(C) Data.--For purposes of determining star 
ratings with respect to measures under the MA Program 
Compliance and Coverage Protection Domain, in addition 
to sources of data otherwise collected under section 
1852(e)(3), the Secretary may use data collected 
pursuant to audits, complaint tracking systems, appeals 
data, determinations made by independent review 
entities, and such other sources as specified by the 
Secretary.
``(D) Application of weighting.--In applying 
section 422.166(e) of title 42, Code of Federal 
Regulations, or a successor regulation, with respect to 
the MA Program Compliance and Coverage Protection 
Domain, the Secretary shall assign a weight to measures 
included under such domain that is greater than the 
weight assigned to measures included under any other 
domain.''.

SEC. 4. GUARDRAILS ON RETROSPECTIVE CLAWBACKS.

(a) Application of Prompt Payment Requirements to All Claims for 
Which Authorization Was Provided.--Section 1857(f) of the Social 
Security Act (42 U.S.C. 1395w-27(f)) is amended--
(1) in paragraph (1)--
(A) in the header, by inserting ``for items and 
services furnished by out-of-network providers of 
services and suppliers'' after ``requirement''; and
(B) by striking ``A contract'' and inserting 
``Subject to paragraph (2), a contract'';
(2) in paragraph (2), by striking ``in compliance with 
paragraph (1)'' and inserting ``in compliance with paragraphs 
(1) and (2)'';
(3) by redesignating paragraphs (2) and (3) as paragraphs 
(3) and (4), respectively; and
(4) by inserting after paragraph (1) the following new 
paragraph:
``(2) Requirement for items and services for which 
authorization was provided.--
``(A) In general.--For contract years beginning on 
or after January 1, 2028, a contract under this part 
shall require a Medicare Advantage organization to 
provide prompt payment (consistent with the provisions 
of sections 1816(c)(2) and 1842(c)(2)) of qualifying 
claims submitted for authorized items and services (as 
defined in subparagraph (B)) furnished to enrollees 
under the plan, except that in applying the provisions 
of such sections--
``(i) references to `not less than 95 
percent of all claims submitted' shall be 
treated as references to `100 percent of all 
claims submitted'; and
``(ii) every qualifying claim (as described 
in subparagraph (C)) submitted for an 
authorized item or service shall be deemed to 
be a clean claim referred to in such sections.
``(B) Authorized item or service defined.--For 
purposes of this paragraph, the term `authorized item 
or service' means an item or service--
``(i) that is furnished by a provider of 
service or supplier to an individual enrolled 
in a Medicare Advantage plan offered by a 
Medicare Advantage organization; and
``(ii) for which approval was provided by 
the Medicare Advantage organization through a 
specified authorization (as defined in section 
1852(g)(1)(C)(iii)).
``(C) Qualifying claim described.--For purposes of 
this paragraph, a claim for an authorized item or 
service is a qualifying claim if it includes 
information sufficient to establish that approval for 
such item or service was provided as described in 
subparagraph (B)(ii).''.
(b) Effect of Specified Authorizations.--Section 1857(e) of the 
Social Security Act (42 U.S.C. 1395e-27(e)) is amended by adding at the 
end the following new paragraph:
``(6) Effect of specified authorizations.--Beginning with 
plan years beginning on or after January 1, 2028, a contract 
under this section with an MA organization shall require that, 
in the case that the MA organization approves the furnishing to 
an individual enrolled under an MA plan offered by such MA 
organization of an item or service through a specified 
authorization (as defined in section 1852(g)(1)(C)(iii)) made 
during the receipt by the individual of such item or service--
``(A) the MA organization may not, after such 
approval, deny coverage of such item or service on the 
basis of lack of medical necessity and may not reopen 
such a decision for any reason except for good cause 
(as described in sections 405.986 and 422.616 of title 
42, Code of Federal Regulations (or any successor 
regulation)) or if there is reliable evidence of fraud 
or similar fault (as such terms are defined in section 
405.902 of such title (or any successor regulation), as 
determined in accordance with section 422.616 of such 
title (or any successor regulation)); and
``(B) the MA organization may not, after such 
approval, change the code assigned with respect to the 
claim for such item or service such that the amount of 
payment for such claim would be reduced, except for 
good cause (as described in subparagraph (A)) or if 
there is reliable evidence of fraud or similar fault 
(as so described).''.
(c) Limitation on Use of Third-Party Post-Claim Review Entities.--
Section 1852(g) of the Social Security Act (42 U.S.C. 1395w-2(g)) is 
amended by adding at the end the following new paragraph:
``(6) Limitations on use of third-party reviews.--
``(A) In general.--For contract years beginning on 
or after January 1, 2028, procedures established by a 
Medicare Advantage organization for making 
determinations under paragraph (1), reconsiderations 
under paragraph (2), or expedited determinations or 
reconsiderations under paragraph (3), and procedures 
established for providing for any post-payment review 
process shall--
``(i) prohibit any third-party entity from 
conducting a medical necessity review for 
coverage, payment, or post-payment review for 
such Medicare Advantage organization unless--
``(I) such review is not with 
respect to an authorized item or 
service (as defined in section 
1857(f)(2)(B)); and
``(II) such entity is in compliance 
with the requirements described in 
subparagraph (B);
``(ii) prohibit the use of any third-party 
review that is conducted using a routine, 
automated process for denials in any such 
review, claim denials, or pattern-based 
practices of changing a code assigned with 
respect to a claim for an item or service 
furnished to individuals enrolled under an MA 
plan offered by the Medicare Advantage 
organization to a code that would result in a 
reduction in the amount of payment for such 
claim after the item or service has been 
furnished to the individual; and
``(iii) prohibit any compensation 
arrangement with any third-party entity that 
provides for payment or other compensation to 
such entity based on the number, percentage, or 
amount of specified authorization requests (as 
defined in section 1852(g)(1)(C)(iii)) that the 
entity approves, denies, or otherwise 
recommends for approval or denial.
``(B) Requirements.--For purposes of subparagraph 
(A), the requirements specified in this subparagraph, 
with respect to a third-party entity and a review 
described in such subparagraph, are each of the 
following:
``(i) The entity conducts such review in 
accordance with audit protocols and appeal 
rights, as applicable, that are specified by 
the Secretary.
``(ii) The entity complies with audit and 
public transparency reporting requirements 
specified by the Secretary.''.

SEC. 5. COVERAGE AND MEDICAL NECESSITY CRITERIA USED BY MEDICARE 
ADVANTAGE ORGANIZATIONS.

(a) Codification Under the Medicare Advantage Program of Two-
Midnight Benchmark and Presumption Rules.--Section 1852(g)(1) of the 
Social Security Act (42 U.S.C. 1395w-22(g)(1)), as amended by section 
2, is further amended by adding at the end the following new 
subparagraph:
``(E) Application of two-midnight rules.--The 
procedures under subparagraph (A) shall provide that, 
for making determinations described in such 
subparagraph with respect to hospital and critical 
access hospital admissions--
``(i) in determining whether an individual 
is an inpatient of a hospital or critical 
access hospital, the Medicare Advantage 
organization shall continue to apply the 
provisions of section 412.3(d) of title 42, 
Code of Federal Regulations, or any successor 
regulation, in the same manner and to the same 
extent as such provisions apply with respect to 
payment under part A; and
``(ii) beginning on January 1, 2028, in 
conducting medical review activities, with 
respect to such admissions, the Medicare 
Advantage organization shall apply the 2-
midnight presumption finalized in the rule 
published by the Secretary in the Federal 
Register on August 19, 2013 (78 Fed. Reg. 
50952), or any successor regulation, in the 
same manner and to the same extent as such 
provisions apply with respect to payment under 
part A.''.
(b) Requiring Consistent Medical Necessity Criteria Between 
Medicare Advantage and Original Fee-for-Service.--
(1) In general.--Section 1852(g) of the Social Security Act 
(42 U.S.C. 1395w-22(g)), as amended by section 4(c), is further 
amended--
(A) in paragraph (2)(B), by striking ``A 
reconsideration relating'' and inserting ``In 
accordance with paragraph (7)(C), a reconsideration 
relating''; and
(B) by adding at the end the following new 
paragraph:
``(7) Medical necessity determined based on ffs reasonable 
and necessary criteria.--
``(A) In general.--For purposes of a determination 
or reconsideration under this subsection made on or 
after January 1, 2028, or a review made on or after 
such date by an independent, outside entity under 
paragraph (4), with respect to coverage for an item or 
service furnished to an individual enrolled in an MA 
plan offered by a Medicare Advantage organization, the 
Medicare Advantage organization or independent, outside 
entity, respectively, shall not apply criteria for 
determining the medical necessity of such item or 
service that is more restrictive than the standards and 
criteria applied pursuant to section 1862(a)(1) for 
determining under parts A and B whether the item or 
service is reasonable and necessary.
``(B) Certain coverage criteria.--For purposes of a 
determination or reconsideration under this subsection 
made on or after January 1, 2028, or a review made on 
or after such date by an independent, outside entity 
under paragraph (4), with respect to coverage of 
inpatient hospital services furnished by a 
rehabilitation facility (as referred to in section 
1866(j)(1)(A)) or long-term care hospital to an 
individual enrolled in an MA plan offered by a Medicare 
Advantage organization, the Medicare Advantage 
organization or independent, outside entity, 
respectively, shall not apply coverage criteria that is 
more restrictive than the standards and criteria 
applied under parts A and B, including under--
``(i) subsections (a)(3), (a)(4), and 
(a)(5) of section 412.622 of title 42, Code of 
Federal Regulations (or any successor to such 
regulation), with respect to such a 
rehabilitation facility; and
``(ii) paragraphs (1), (3), and (4) of 
section 1861(ccc) and clauses (iii) and (iv) of 
section 1886(m)(6)(A), with respect to a long-
term care hospital.
``(C) Personnel.--For purposes of subparagraph (A), 
a determination, reconsideration, or review regarding 
the medical necessity of an item or service shall be 
made only by a physician or other health care 
professional with appropriate expertise, including 
education, with respect to such item or service and the 
related standards and criteria applied pursuant to 
section 1862(a)(1). For purposes of subparagraph (B), a 
determination, reconsideration, or review regarding 
coverage of inpatient hospital services furnished by a 
facility or hospital described in such subparagraph 
shall be made only by a physician or other health care 
professional with appropriate expertise, including 
education, with respect to such services and the 
related standards and criteria applied pursuant to such 
subparagraph.''.
(2) Enforcement.--Section 1857(g)(1) of the Social Security 
Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(A) by redesignating subparagraph (K) as 
subparagraph (L);
(B) by striking ``or'' at the end of subparagraph 
(J);
(C) by inserting after subparagraph (J) the 
following subparagraph:
``(K) fails to comply with section 1852(g)(7); 
or'';
(D) in subparagraph (L), as redesignated by 
subparagraph (A), by striking ``subparagraphs (A) 
through (J)'' and inserting ``subparagraphs (A) through 
(K)''; and
(E) in the matter following such subparagraph (L), 
by striking ``subparagraphs (A) through (K)'' and 
inserting ``subparagraphs (A) through (L)''.
(c) Requiring Transparency in Coverage Criteria.--Section 
1852(a)(2) of the Social Security Act (42 U.S.C. 1395w-22(a)(2)) is 
amended by adding at the end the following new subparagraph:
``(D) Transparency in coverage criteria.--
``(i) Requirement.--For plan years 
beginning on or after January 1, 2028, in order 
to meet the requirement under paragraph (1)(A), 
in the case of an item or service for which 
there is no national coverage determination, 
applicable local coverage determination, or 
applicable guidance for coverage provided by 
the Secretary, a Medicare Advantage 
organization offering an MA plan shall--
``(I) make a coverage determination 
with respect to such item or service in 
accordance with publicly available 
evidence-based coverage criteria that 
is published on a public website of the 
Medicare Advantage organization; and
``(II) submit to the Secretary 
information, with respect to every 
medical necessity determination made in 
the absence of such national coverage 
determination, applicable local 
coverage determination, or applicable 
guidance for coverage, specifying the 
coverage criteria applied under the MA 
plan.
``(ii) Use of information.--The Secretary 
shall use the information submitted under 
clause (i)(II) to prioritize coverage 
determinations.''.

SEC. 6. ELIMINATING INEFFICIENCIES IN ADMINISTRATIVE PROCESSING BY 
MEDICARE ADVANTAGE ORGANIZATIONS.

(a) Applying Fee-for-Service Prompt Payment Requirements to MA In-
Network Services as Well as Out-of-Network Services.--Section 
1857(f)(1) of the Social Security Act (42 U.S.C. 1395w-27(f)(1)), as 
amended by section 4(a), is further amended--
(1) in the paragraph heading, by inserting ``in-network 
and'' before ``out-of-network''; and
(2) by striking ``if the services or supplies'' and all 
that follows through the period at the end and inserting 
``regardless of whether the services or supplies are furnished 
under a contract between the organization and the provider of 
services or supplier. A claim that is determined to be a clean 
claim pursuant to the previous sentence or paragraph (2) may 
not subsequently be determined to not be a clean claim except 
under such circumstances and in accordance with such criteria 
as specified by the Secretary pursuant to notice and comment 
rulemaking.''.
(b) Automated Review and Payment for Certain Claims.--Section 
1857(f) of the Social Security Act (42 U.S.C. 1395w-27(f)), as amended 
by section 4(a), is further amended--
(1) by redesignating paragraphs (3) and (4) as paragraphs 
(4) and (5), respectively; and
(2) by inserting after paragraph (2) the following new 
paragraph:
``(3) Automated review and payment for certain claims.--
``(A) In general.--For plan years beginning on or 
after January 1, 2028, a Medicare Advantage 
organization shall have in place automated payment 
processes, in accordance with standards specified by 
the Secretary, for claims described in subparagraph (B) 
with respect to which the provisions of paragraph (1) 
or (2) apply. Such processes shall provide that such 
claims shall be automatically processed and paid and 
shall not be subject to manual claim review, except in 
cases for which there is reasonable evidence of fraud.
``(B) Specified claims.--For purposes of 
subparagraph (A), a claim described in this 
subparagraph is a claim that--
``(i) is for an authorized item or service 
(as defined in paragraph (2)(B)); or
``(ii) is for an item or service identified 
on the most recent list published pursuant to 
section 1852(g)(1)(D)(iii).''.

SEC. 7. MODIFICATION TO NETWORK ADEQUACY STANDARDS FOR CERTAIN POST-
ACUTE CARE PROVIDERS.

Section 1852(d)(1) of the Social Security Act (42 U.S.C. 1395w-
22(d)(1)) is amended--
(1) in subparagraph (D), by striking ``and'' at the end;
(2) in subparagraph (E), by striking the period at the end 
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(F) for plan years beginning on or after January 
1, 2028, the organization provides adequate access to 
long-term care hospitals and inpatient rehabilitation 
facilities, as determined in accordance with network 
adequacy standards specified by the Secretary.''.
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