Medicare Advantage Improvement Act of 2026

This bill makes several changes to the Medicare Advantage (MA) program under Medicare Part C, effective mostly from 2028, to improve enrollee access to timely care, strengthen oversight, limit retroactive claim denials, align medical necessity rules with original Medicare, streamline administrative processing, and update network adequacy standards for certain post-acute care providers.

Sec. 2, Improving access to timely care: Starting January 1, 2028, MA plans must respond to most prior authorization and concurrent coverage requests within 72 hours (standard) or 24 hours (expedited), with possible extensions up to 7 days for specific reasons. The Secretary may later change these deadlines by rulemaking. Also from 2028, MA organizations must report prior authorization data at the plan and parent-organization level, broken down by provider and service category, and make it publicly available.

Sec. 3, Ensuring appropriate oversight: For plan years beginning on or after January 1, 2028, the Secretary must create a compliance scoring program for MA organizations. Based on their compliance with categories like timely authorization decisions, coverage criteria, prompt payment, and marketing rules, organizations will be assigned a compliance tier and face payment reductions of 1.0%, 1.5%, or 2.0% for noncompliance.

Sec. 4, Guardrails on retrospective clawbacks: For contract years starting on or after January 1, 2028, MA plans must pay 100% of clean claims for items or services that were pre-approved through a specified authorization. Once an MA plan approves an item or service during a patient's stay, it cannot later deny coverage for lack of medical necessity or change the billing code to reduce payment, except for good cause or fraud. Third-party entities cannot conduct medical necessity reviews on authorized items or services, and automated denial processes are prohibited.

Sec. 5, Coverage and medical necessity criteria: Starting January 1, 2028, MA plans must apply the same two-midnight benchmark and presumption rules for inpatient hospital admissions as original Medicare. MA plans cannot use medical necessity criteria more restrictive than original Medicare's reasonable and necessary standard, and coverage criteria for inpatient rehab and long-term care hospitals must match original Medicare rules. Only physicians or appropriate health professionals can make these determinations.

Sec. 6, Eliminating administrative inefficiencies: For plan years beginning on or after January 1, 2028, prompt payment requirements apply to both in-network and out-of-network claims. MA plans must use automated payment processes for claims involving pre-authorized items or services, or items on a specified list, without manual review unless there is evidence of fraud.

Sec. 7, Network adequacy for post-acute care: For plan years beginning on or after January 1, 2028, MA plans must provide adequate access to long-term care hospitals and inpatient rehabilitation facilities, as determined by the Secretary's network adequacy standards.