No CRS summary available for this bill.
This section reduces timeframes for Medicare Advantage organizations to respond to specified authorization requests and requires real-time decisions for certain identified services. (1) For standard organization determinations regarding a specified authorization (i.e., prior authorization, preservice coverage or payment determination, concurrent determination, or hospital or post-acute care transfer authorization) for an enrollee, requires notification of the determination as expeditiously as the enrollee’s health condition requires but no later than 72 hours after receipt of the request for requests made on or after January 1, 2028, with extensions of up to 7 calendar days permitted if requested by the enrollee, needed to obtain evidence from a non-contracted provider, or justified by extraordinary circumstances; the Secretary may modify the deadline through rulemaking for requests made on or after January 1, 2030. (2) For expedited organization determinations related to a specified authorization, requires notification within 24 hours after receipt of the request or necessary information for requests made on or after January 1, 2028. (3) Beginning with plan years on or after January 1, 2028, requires Medicare Advantage organizations to report prior authorization data at the plan and parent organization levels (in addition to the contract level), in a manner allowing comparisons by provider and service category, and in a downloadable format accessible for research and oversight. (4) Establishes procedures for real-time authorization decisions for identified services.
This section establishes a Medicare Advantage organization (MAO) compliance scoring and accountability program under which the Secretary assesses, at the plan level, each MAO’s compliance with requirements in six specified categories—including timely prior authorization decisions, coverage criteria standards, prompt payment, restrictions on improper retroactive denials, marketing and enrollment rules, and other program requirements—using audits, reporting, and performance measures. The Secretary assigns each MAO a total compliance score on a 0-to-100 scale, with equal weight given to each category, and places the MAO into one of three noncompliance tiers. For plan years beginning on or after January 1, 2028, the Secretary reduces total monthly capitation payments to an MAO in the lowest tier by 2.0 percent, in the middle tier by 1.5 percent, and in the highest tier by 1.0 percent. The Secretary implements the program through notice-and-comment rulemaking and may update the compliance categories.
This section limits retrospective denials, payment reductions, and clawbacks by Medicare Advantage organizations after they issue specified authorizations for items and services. (1) It requires Medicare Advantage contracts, for contract years beginning on or after January 1, 2028, to provide prompt payment of 100 percent of qualifying claims for authorized items and services (i.e., those approved through a specified authorization), treating every such claim as a clean claim under sections 1816(c)(2) and 1842(c)(2) of the Social Security Act. (2) It prohibits Medicare Advantage organizations, beginning with plan years on or after January 1, 2028, from denying coverage of an authorized item or service on the basis of lack of medical necessity or from reopening the decision except for good cause or reliable evidence of fraud or similar fault, and from changing the code assigned to the claim in a manner that reduces payment except under the same exceptions. (3) It bars Medicare Advantage organizations from using third-party entities to conduct medical necessity or post-payment reviews of authorized items and services, prohibits routine automated processes for denials or downcoding after services are furnished, and restricts compensation arrangements with third-party reviewers that are based on the volume or outcomes of authorization decisions.
This section codifies under the Medicare Advantage program the two-midnight benchmark and presumption rules that apply to inpatient hospital and critical access hospital admissions under original Medicare, requiring Medicare Advantage organizations to apply the provisions of 42 C.F.R. § 412.3(d) and, beginning January 1, 2028, the two-midnight presumption finalized in the August 19, 2013 Federal Register rule. This section further requires that, for coverage determinations, reconsiderations, and independent reviews made on or after January 1, 2028, Medicare Advantage organizations and outside entities apply medical necessity criteria no more restrictive than the reasonable and necessary standards used under parts A and B pursuant to section 1862(a)(1), including specific coverage criteria under 42 C.F.R. § 412.622(a)(3)–(5) for inpatient rehabilitation facility services and under sections 1861(ccc) and 1886(m)(6)(A) for long-term care hospital services. Such determinations must be made only by a physician or other health care professional with appropriate expertise in the item or service and related criteria. This section adds enforcement authority under section 1857(g)(1) for failures to comply with these medical necessity requirements and requires Medicare Advantage organizations, for plan years beginning on or after January 1, 2028, to publish publicly available evidence-based coverage criteria on their websites and submit related information to the Secretary when no national or local coverage determination applies.
This section applies fee-for-service prompt payment requirements to Medicare Advantage in-network services as well as out-of-network services and prohibits a Medicare Advantage organization from subsequently reclassifying a clean claim except under criteria specified by the Secretary through notice-and-comment rulemaking. It further requires Medicare Advantage organizations, for plan years beginning on or after January 1, 2028, to maintain automated processes that automatically review and pay claims for authorized items or services (or items or services on the list published under section 1852(g)(1)(D)(iii)) without manual review, except where there is reasonable evidence of fraud.
This section modifies Medicare Advantage (MA) network adequacy standards by requiring MA organizations, for plan years beginning on or after January 1, 2028, to provide adequate access to long-term care hospitals and inpatient rehabilitation facilities in accordance with standards specified by the Secretary. (As background, MA plans must currently demonstrate adequate access to specified provider types under section 1852(d)(1) to ensure enrollees can obtain covered services within reasonable travel time and distance.)