Six lawmakers from both parties, led by Pennsylvania Republican John Joyce, introduced H.R. 8375, the Medicare Advantage Improvement Act, on April 23, 2026, alongside a Senate companion bill from Kansas Republican Roger Marshall and Rhode Island Democrat Sheldon Whitehouse. The measure would force Medicare Advantage insurers, which now cover more than half of all Medicare beneficiaries, to decide routine prior authorization requests within 72 hours and urgent ones within 24 hours, replacing the open-ended review windows insurers have used to delay care for weeks at a time. It follows warnings from hospital and rehabilitation executives that plans have been denying treatment their own doctors already approved.
What the Bill Would Require Before an Insurer Can Say No
The bill’s core mechanism sets hard clocks on the review process that has drawn the most complaints from patients and providers. Under H.R. 8375, a Medicare Advantage plan would have to decide a standard prior authorization request within 72 hours of submission and an expedited request within 24 hours, then resolve a general appeal within 14 days and an expedited appeal within 24 hours. The bill also requires real-time approval for routine, low-risk services with historically high approval rates, and it orders plans to publicly report their prior authorization data, a disclosure insurers have resisted providing in a standardized format.
Three of the bill’s House sponsors are practicing physicians, and their statements frame the legislation as a firsthand complaint about how Medicare Advantage actually operates. Joyce said the program’s promise has been undermined by unnecessary barriers to care, particularly through excessive use of prior authorization and inappropriate coverage denials in Medicare Advantage, while Iowa Republican Mariannette Miller-Meeks and California Democrat Ami Bera each cited delays they had witnessed treating patients enrolled in the plans. The bill would require medical necessity determinations to follow the same standards used in traditional Medicare fee-for-service coverage and be made by clinicians with relevant expertise, rather than by internal criteria a plan sets on its own.
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Tying Denials to the Money Plans Already Collect
The bill’s leverage runs through the payment system Medicare Advantage plans depend on for their bonus revenue. H.R. 8375 would create a compliance scoring system, backed by financial penalties, and add a heavily weighted new domain to the Star Ratings CMS already uses to grade plans each year. A plan that delays care, denies services inappropriately, or otherwise fails to meet the bill’s requirements would face payment reductions and public reporting of its compliance score alongside its ratings, attaching a dollar cost to behavior industry groups say plans currently absorb as a routine cost of doing business.
That incentive structure is central to why the bill targets Star Ratings rather than penalties alone. Medicare pays Medicare Advantage plans a fixed monthly amount per enrollee, so a plan’s margin improves whenever it avoids paying for a service, and prior authorization has functioned as the primary tool for managing that utilization. By attaching compliance scores to the ratings that also drive federal bonus payments, the bill aims at the revenue mechanism that made expansive prior authorization profitable in the first place, rather than relying on penalties a large insurer could absorb without changing behavior.
The bill also targets a narrower but more direct grievance: insurers approving a service in advance, then refusing to pay for it once delivered. H.R. 8375 would bar Medicare Advantage plans from denying payment on a claim after granting prior authorization for that same service, and would prohibit downcoding, reducing a claim’s payment level after the fact, except in cases of confirmed fraud or error. It pairs that ban with prompt-payment requirements covering both in-network and out-of-network claims and requires automated payment for authorized, routine services treated as clean claims, removing a second layer of review insurers currently apply after care is already finished.
A Long Way From Becoming Law
Nothing in that structure takes effect unless Congress acts. H.R. 8375 was referred to committee after its April 23 introduction, and no committee vote, floor vote, or Congressional Budget Office cost estimate has followed. Its Senate companion, S. 4384 from Marshall and Whitehouse, gives the effort a bicameral track, but a bill needs floor time and a matching companion passed in both chambers before it reaches a presidential desk, and this Congress has scheduled neither.
Support so far comes almost entirely from the provider side of the industry rather than from the insurers whose review practices the bill would restrict. Ascension chief executive Eduardo Conrado, the American Medical Rehabilitation Providers Association, PAM Health, Community Health Systems and Encompass Health each issued statements backing the bill, citing delays and denials their own clinicians and hospitals had documented.
The nursing home trade group AHCA/NCAL is urging members to raise the bill directly with lawmakers at a Washington briefing scheduled for June 8 and 9, treating floor time as something that has to be lobbied into existence rather than assumed. None of the major Medicare Advantage insurers whose prior authorization practices the bill targets has filed a public position on H.R. 8375.
That asymmetry is the bill’s real test. A compliance scoring system tied to Star Ratings and a ban on retroactive denials would only change insurer behavior if the provisions survive committee markup intact, and Medicare Advantage oversight proposals in past Congresses have often been narrowed before reaching a vote. Whether this one keeps its enforcement mechanisms, or is rewritten into guidance insurers can manage around, will not be visible until the bill clears its first committee, which had not happened as of this reporting.
This article was researched and drafted with the assistance of artificial intelligence.
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