The Medicare Advantage Improvement Act of 2026 would significantly revise Medicare Advantage prior authorization, appeals, payment, and oversight rules beginning in 2028, with some Secretary rulemaking authority beginning in 2030. The bill shortens response times for standard prior authorization requests to 72 hours and expedited requests to 24 hours, creates a real-time authorization system for certain low-risk or high-approval services submitted through certified EHR technology, and bars plans from requiring a new authorization when a previously approved service is clinically modified, extended, or adjusted during treatment. It also requires more detailed public reporting on prior authorization activity at the plan and parent-organization levels, including downloadable data for research and enforcement.
The bill further tightens appeals and payment protections. It requires faster reconsideration timelines, gives enrollees and providers an opportunity to submit supporting documentation, and limits post-approval denials, coding changes, and third-party utilization review practices that can reduce payment after care has been furnished. It also applies prompt-payment rules more broadly, including to in-network claims, and requires automated payment processing for certain claims tied to approved services or services on the Secretary’s identified list. In addition, the bill codifies Medicare Advantage coverage standards to align more closely with traditional Medicare, including the two-midnight rule, the two-midnight presumption, and a prohibition on using more restrictive medical-necessity or coverage criteria than original fee-for-service Medicare for covered items and services.
On the oversight side, the bill creates a new MAO Compliance and Accountability Program under which CMS would assess plans across multiple compliance categories, assign scores from 0 to 100, place organizations into compliance tiers, and reduce monthly payments for lower-performing organizations. It also expands the Medicare Advantage Star Ratings program by adding a new compliance and coverage protection domain, with publicly reported measures and heavier weighting than other domains. The bill requires transparency in coverage criteria when no national or local coverage determination exists, and it directs CMS to use plan-submitted criteria information to prioritize coverage determinations.
The general sentiment reflected by the bill’s structure is strongly pro-consumer and pro-provider in the sense of reducing administrative delays, increasing transparency, and limiting plan discretion. Because there are no committee transcripts or recorded votes in the provided context, there is no direct evidence of formal support or opposition in debate. However, the bill’s extensive new compliance duties, public reporting requirements, and payment penalties suggest that Medicare Advantage organizations would likely be the principal regulated parties and may view the measure as burdensome or costly, while beneficiaries, hospitals, physicians, and post-acute providers would likely favor the added access and payment protections.
The main points of contention are likely to center on whether the bill goes too far in constraining plan management tools such as prior authorization, retrospective review, and medical-necessity determinations. Another likely issue is administrative feasibility, especially the real-time authorization mandate, interoperability with certified EHR systems, and the Secretary’s ability to implement new standards through rulemaking. The bill also raises questions about how compliance scores and star ratings will be calculated, whether the new public disclosures could be used for enforcement or litigation, and whether the prompt-payment and anti-clawback provisions could increase costs for Medicare Advantage plans and, indirectly, the Medicare program.
The bill would amend title XVIII of the Social Security Act to impose new federal requirements on Medicare Advantage organizations, affecting sections governing organization determinations, reconsiderations, prompt payment, coverage criteria, network adequacy, and plan oversight. It would create new statutory duties for CMS and MA plans, including faster authorization decisions, real-time approvals for certain services, stricter limits on post-service denials and third-party reviews, new transparency reporting, and a compliance scoring system tied to payment reductions and star ratings. These changes would directly affect Medicare Advantage enrollees, plans, providers, suppliers, and CMS oversight operations.
The bill’s overall sentiment is favorable toward beneficiaries and providers who seek faster coverage decisions, fewer denials, and stronger appeal rights. The text reflects a clear policy preference for transparency, accountability, and alignment with original Medicare standards. No votes or committee discussion were provided, so there is no recorded legislative debate to indicate formal support or opposition, but the bill’s design suggests likely support from patient advocates and provider groups and likely resistance from Medicare Advantage insurers and organizations concerned about administrative burden and reduced utilization-management flexibility.
The most likely areas of contention are the bill’s restrictions on prior authorization, retrospective review, and third-party utilization management, especially the limits on post-approval denials and coding changes. Medicare Advantage organizations may object to the mandatory 72-hour and 24-hour response windows, the real-time authorization infrastructure, and the requirement to use less restrictive coverage criteria than original Medicare. Another likely dispute is the compliance scoring and payment-reduction regime, which could be viewed as punitive or difficult to administer, while supporters would argue it is necessary to curb delays, denials, and opaque plan practices.