[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4559 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 4559
To amend title XVIII of the Social Security Act to establish payment
parity between Medicare Advantage and fee-for-service Medicare, and to
establish prompt payment requirements under Medicare Advantage.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 21, 2025
Mr. Doggett (for himself and Mr. Murphy) introduced the following bill;
which was referred to the Committee on Ways and Means, and in addition
to the Committee on Energy and Commerce, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to establish payment
parity between Medicare Advantage and fee-for-service Medicare, and to
establish prompt payment requirements under Medicare Advantage.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Prompt and Fair Pay Act''.
SEC. 2. ESTABLISHING PAYMENT PARITY BETWEEN MEDICARE ADVANTAGE AND FEE-
FOR-SERVICE MEDICARE.
Section 1857(e) of the Social Security Act (42 U.S.C. 1395w-27(e))
is amended by adding at the end the following new paragraph:
``(6) Payment parity with fee-for-service medicare.--
Beginning with plan years beginning on or after January 1,
2027, a contract under this part shall require an MA
organization to provide, in any contract between the
organization and a provider or supplier, that payment for items
and services furnished to an enrollee by such provider or
supplier shall be in an amount that is not less than the amount
of payment applicable on the date of service for such items and
services under the original Medicare fee-for-service program
under parts A and B, including cost-based payment
methodologies.''.
SEC. 3. PROTECTING BENEFICIARY ACCESS TO CARE UNDER MEDICARE ADVANTAGE
BY ESTABLISHING ENFORCEABLE PROMPT PAYMENT REQUIREMENTS
AND ENHANCING TRANSPARENCY REGARDING CLAIMS DENIALS.
(a) Applying Prompt Payment Requirements for Items and Services
Furnished by In-Network Providers.--
(1) In general.--Section 1857(f) of the Social Security Act
(42 U.S.C. 1395w-27(f)) is amended--
(A) in paragraph (1), in the header, by inserting
``Applicable with respect to out-of-network providers
of services and suppliers'' after ``Requirement'';
(B) in paragraph (2), by striking ``compliance with
paragraph (1)'' and inserting ``compliance with
paragraph (1) or (2)'';
(C) by redesignating paragraphs (2) and (3) as
paragraphs (3) and (4), respectively; and
(D) by inserting after paragraph (1) the following
new paragraph:
``(2) Requirement applicable with respect to in-network
providers of services and suppliers.--
``(A) Prompt payment of clean claims.--
``(i) In general.--For contract years
beginning on or after January 1, 2027, a
contract entered into with an MA organization
with respect to offering an MA plan under this
part shall require that contracts and other
agreements between such MA organization and
providers of services and suppliers to furnish
items and services to enrollees under such plan
shall provide that payment shall, in accordance
with the provisions of this paragraph, be
issued, mailed, or otherwise transmitted, with
respect to all clean claims submitted for such
items and services furnished by such providers
of services and suppliers to such enrollees, by
not later than the applicable number of
calendar days (as defined in clause (iii))
after the date on which the claim is received
(as determined in accordance with clause (ii)).
``(ii) Date of receipt of claim.--For
purposes of this paragraph, a claim is
considered to have been received--
``(I) with respect to claims
submitted electronically, on the date
on which the claim is transferred; and
``(II) with respect to claims
submitted otherwise, on the 5th day
after the postmark date of the claim or
the date specified in the time stamp of
transmission.
``(iii) Applicable number of calendar days
defined.--For purposes of this paragraph, the
term `applicable number of calendar days'
means--
``(I) with respect to claims
submitted electronically, 14 days; and
``(II) with respect to claims
submitted otherwise, 30 days.
``(B) Procedures and rules for determining whether
claims are clean claims.--
``(i) Clean claim defined.--In this
paragraph, the term `clean claim' means--
``(I) a claim that has no defect or
impropriety (including any lack of any
required substantiating documentation)
or particular circumstance requiring
special treatment that prevents timely
payment from being made on the claim
under this part; and
``(II) a claim that otherwise
conforms to the clean claim
requirements for equivalent claims
under original Medicare.
``(ii) Claim deemed to be clean when timely
notice of any deficiency is not provided.--For
purposes of this paragraph, with respect to an
MA organization and a provider of services or
supplier with whom the MA organization has a
contract to furnish items and services, a claim
for such items and services furnished by such
provider of services or supplier under such
contract shall be deemed to be a clean claim if
the MA organization does not provide notice to
the provider of services or supplier of any
deficiency in the claim--
``(I) with respect to claims
submitted electronically, within 10
days after the date on which the claim
is received; and
``(II) with respect to claims
submitted otherwise, within 15 days
after the date on which the claim is
received.
``(iii) Required notifications and
treatment of claims initially determined to not
be clean claims.--For purposes of this
paragraph, with respect to an MA organization
and a provider of services or supplier with
whom the MA organization has a contract to
furnish items and services--
``(I) if the MA organization
determines that a submitted claim for
such items and services furnished by
such provider of services or supplier
under such contract is not a clean
claim, the MA organization shall, not
later than the end of the applicable
period described in clause (ii), notify
the provider of services or supplier of
such determination and in such
notification shall specify all defects
or improprieties in the claim and shall
list all additional information or
documents necessary for the proper
processing and payment of the claim,
including detailed instructions for
resubmission of claims, how to address
each specified defect or impropriety,
any formatting or coding guidance
specific to the rejection reason, and
how to contact the plan to obtain
assistance with resubmission; and
``(II) in the case in which
additional information is received
pursuant to a notification under
subclause (I) with respect to a claim
described in such subclause, the claim
shall be deemed to be a clean claim
described in clause (i) if the MA
organization does not provide notice to
the provider of service or supplier of
any defect or impropriety in the claim
not later than 10 days of the date on
which such additional information is
received.
``(iv) Rule of construction.--A
determination under this paragraph that a claim
submitted by a provider of services or supplier
is a clean claim shall not be construed as a
positive determination regarding eligibility
for payment under this title, nor is it an
indication of government approval of, or
acquiescence regarding, the claim submitted.
The determination shall not relieve any party
of civil or criminal liability with respect to
the claim, nor does it offer a defense to any
administrative, civil, or criminal action with
respect to the claim.
``(C) Obligation to pay.--For purposes of this
paragraph:
``(i) In general.--A claim submitted to an
MA organization that is not paid or contested
by the organization within the applicable
number of calendar days (as defined in
subparagraph (A)(iii)) after the date on which
the claim is received (as determined in
accordance with subparagraph (A)(ii)) shall be
deemed to be a clean claim and shall be paid by
the MA organization in accordance with
subparagraph (A)(i).
``(ii) Electronic transfer of funds.--An MA
organization shall pay all clean claims
submitted electronically by electronic transfer
of funds if the provider of services or
supplier so requests or has so requested
previously. In the case in which such payment
is made electronically, remittance may be made
by the MA organization electronically as well.
``(iii) Date of payment of claim.--Payment
of a clean claim under this paragraph shall be
considered to have been made on the date on
which--
``(I) with respect to claims paid
electronically, the payment is
transferred; and
``(II) with respect to claims paid
otherwise, the payment is submitted to
the United States Postal Service or
common carrier for delivery.
``(D) Interest payment.--
``(i) For purposes of this paragraph,
subject to clause (ii), if payment is not
issued, mailed, or otherwise transmitted within
the applicable number of calendar days (as
defined in subparagraph (A)(iii)) after a clean
claim (with respect to which this paragraph
applies) is received, the MA organization shall
pay interest to the provider of services or
supplier that submitted the claim at a rate
equal to the weighted average of interest on 3-
month marketable Treasury securities determined
for such period, increased by 0.1 percentage
point for the period beginning on the day after
the required payment date and ending on the
date on which payment is made (as determined
under subparagraph (C)(iii)). Interest amounts
paid under this subparagraph shall not be
counted against the administrative costs of an
MA plan for purposes of determining the medical
loss ratio of the plan under subsection (e)(4).
``(ii) Authority not to charge interest.--
The Secretary may provide that an MA
organization is not charged interest under
clause (i) in the case in which there are
exigent circumstances, including natural
disasters and other unique and unexpected
events, that prevent the timely processing of
claims.
``(E) Protecting the rights of claimants.--
``(i) In general.--Nothing in this
paragraph shall be construed to prohibit or
limit a claim or action not covered by the
subject matter of this paragraph that any
individual or organization has against a
provider of services, supplier, or an MA
organization.
``(ii) Anti-retaliation.--Consistent with
applicable Federal and State laws, an MA
organization shall not retaliate against an
individual, provider of services, or supplier
for exercising a right of action under this
subparagraph.''.
(2) Secretarial authority to enforce prompt payment
requirement.--Section 1857(g)(1) of the Social Security Act (42
U.S.C. 1395w-27(g)(1)) is amended--
(A) in subparagraph (J), by striking at the end
``or'';
(B) in subparagraph (K), by inserting ``or'' after
the semicolon; and
(C) by inserting after subparagraph (K) the
following new subparagraph:
``(L) fails to comply with the provisions of
subsection (f)(2);''.
<all>