To amend title XVIII of the Social Security Act to establish certain requirements with respect to rates of reversed prior authorization coverage determinations under Medicare Advantage plans.

This bill changes Medicare law for Medicare Advantage plans that require prior authorization before covering certain items or services. Starting with plan years that begin at least one year after the bill becomes law, the federal Secretary of Health and Human Services would have to end a plan's contract if more than 25 percent of its prior authorization denials are later reversed on reconsideration or appeal. A contract would also be ended if the Secretary finds that reversals on reconsideration dropped significantly from the year before because the plan failed to properly reconsider its decisions. The bill also changes the existing contract-termination procedures in cases where a contract is ended for failing to meet this requirement.

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Sponsors

• Mark Pocan Democrat sponsor
• 18 cosponsors