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HR 8375

Medicare Advantage Improvement Act of 2026

119th Congress Introduced by Ami Bera and 12 co-sponsors

The bill tightens MA authorizations and oversight to speed care, align medical necessity with traditional Medicare, boost transparency, and hold MAOs to stricter compliance and rep

Sponsor introductory remarks on measure. (CR H3095)
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Bill Summary · HR 8375

Summary of HR 8375 — Medicare Advantage Improvement Act of 2026 (119th Congress)

Purpose and overall intent

  • The bill aims to reform and strengthen the Medicare Advantage (MA) program (Title XVIII of the Social Security Act) by increasing access to timely care, accelerating certain authorization decisions, enhancing transparency and oversight, improving medical necessity standards and post-authorization protections, and tightening enforcement and accountability for MA organizations (MABOs). It also extends certain operational improvements to in-network and out-of-network providers, and updates post-acute care network adequacy standards.

Key provisions and changes

1) Timely access to care and faster responses to authorization requests

  • Establishes new and expanded timeframes for MA organizations to respond to authorization requests (specified authorizations) for MA enrollees.
  • For requests made on or after January 1, 2028:
    • The MA organization must notify enrollees, physicians, and involved providers of determinations as expeditiously as the health condition requires, but no later than 72 hours after receipt of the request (with allowances for extensions of up to 7 days under defined circumstances).
    • Introduces an expedited timeframe for certain determinations related to identified services, with similar 24-hour notification deadlines for the most urgent cases starting in 2028.
  • Adds requirements for real-time determinations for certain items/services, including integration with certified EHR technology and immediate notification to providers when determinations are made.
  • Requires annual publication (starting plan year 2028) of a list identifying which items/services require real-time authorization, and expands plan-level data reporting and public availability of real-time decision metrics.

2) Expanded real-time authorizations and transparency

  • Real-time determinations (for specific authorizations) must be implemented, with the Secretary allowed to publish a list each year identifying:
    • Items/services where ≥90% of prior-year requests were approved
    • Clinically low-risk and routine items/services
    • Items/services that represent high volume or administrative burden
  • MAOs must provide quarterly public reports to CMS on real-time determinations, including approval/denial rates, appeals, overturns, and provider complaints, with public posting and an opportunity for corrections before public release.

3) Prohibiting certain authorization requirements for clinically necessary changes

  • Beginning Jan 1, 2028, MAOs may not require a new specified authorization when a provider makes clinically necessary modifications, extensions, or adjustments to an approved item/service. Documentation or post-service notification may still be required.

4) Oversight, compliance scoring, and accountability

  • Creates an MAO Compliance Program that assigns a plan-level compliance score (0-100) and places MAOs into compliance tiers (1 to 4) based on performance across several categories (e.g., timely decision-making, coverage criteria, prompt payment, marketing/enrollment rules, and other statutory requirements).
  • Establishes a process for MAOs to be reviewed and, if necessary, corrected, with public disclosures of compliance scores and opportunities for MAOs to review and correct information prior to public posting.
  • Expands the MA Star Ratings framework to include an MA Program Compliance and Coverage Protection Domain, with various data sources (audits, complaints, appeals, independent reviews) feeding into star ratings and giving greater weight to compliance measures.

5) Consistency of medical necessity criteria with fee-for-service (FFS)

  • Requires consistency between MA medical necessity determinations and the standards used under Parts A and B of the original Medicare (e.g., 1862(a)(1) criteria). This applies to determinations, reconsiderations, and independent reviews.
  • For inpatient rehab facilities and long-term care hospitals, ensures non-restrictive coverage standards aligned with FFS standards and specifies that qualified determinations should be made by appropriately trained professionals.

6) Curbs on retrospective clawbacks and third-party reviews

  • Applies prompt payment rules to claims submitted by out-of-network providers for MA plans, and tightens payment timelines for qualifying claims (with adjusted expectations for clean claims).
  • Limits third-party post-payment reviews and automated denial practices, prohibits compensation structures that reward the volume of prior authorization approvals/denials, and requires compliance with audit and transparency standards.

7) Network adequacy and post-acute care access

  • Strengthens network adequacy standards to ensure adequate access to long-term care hospitals and inpatient rehabilitation facilities for MA enrollees, effective for plan years beginning January 1, 2028.

8) Transparency in coverage criteria

  • Requires MAOs to use publicly available evidence-based coverage criteria when no national/local guidance exists and to share information with CMS to inform prioritization of coverage determinations.

Who is affected

  • Medicare Advantage organizations (MAOs) that contract with CMS to offer MA plans.
  • MA enrollees and their providers (physicians, hospitals, and suppliers) who rely on prior authorizations and covered services.
  • Independent, outside review entities currently involved in reconsiderations or reviews of MA determinations.
  • Providers of services and suppliers (including out-of-network providers) who submit claims or engage in post-authorization processes.
  • CMS, as the administrator of the MA program and Star Ratings system.

Procedural and timeline aspects

  • Effective dates primarily focus on plan years beginning on or after January 1, 2028 for many new requirements (timely responses, real-time determinations, MAO compliance program, and MA star rating domain).
  • Some early provisions (notably around data reporting and plan-level transparency) reference plan years beginning in 2028.
  • The bill provides for rulemaking by the Secretary (HHS CMS) to define timing, processes, and data reporting standards.
  • It includes expanded oversight and potential payment adjustments to MAOs based on compliance scores, with public disclosure to inform beneficiaries.

Observations

  • The bill emphasizes timely care, stricter enforcement, and greater transparency in authorization and coverage decisions within Medicare Advantage.
  • It seeks to align MA medical necessity standards with traditional Medicare FFS criteria and to reduce inefficient administrative practices, including over-reliance on third-party reviews and retrospective clawbacks.
  • The package broadens MA program integrity with enhanced data sharing and public reporting, potentially influencing MA plan design, operations, and beneficiary experience.

Compiled from official sources — confirm details with the bill’s official record.

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