[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5454 Introduced in House (IH)]
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119th CONGRESS
1st Session
H. R. 5454
To amend title XVIII of the Social Security Act to apply improved
prompt payment requirements to Medicare Advantage organizations.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 18, 2025
Mr. Arrington (for himself and Ms. Sanchez) 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 apply improved
prompt payment requirements to Medicare Advantage organizations.
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 ``Medicare Advantage Prompt Pay Act''.
SEC. 2. APPLICATION OF IMPROVED PROMPT PAYMENT REQUIREMENTS TO MEDICARE
ADVANTAGE ORGANIZATIONS.
(a) Requirements.--
(1) In general.--Section 1857 of the Social Security Act
(42 U.S.C. 1395w-27) is amended--
(A) in subsection (f), by striking paragraph (1)
and inserting the following:
``(1) Requirements.--
``(A) Items and services furnished by in-network
and out-of-network providers of services and
suppliers.--
``(i) In general.--A contract under this
part between the Secretary and a Medicare
Advantage organization offering a Medicare
Advantage plan shall require the organization
to provide prompt payment for not less than 95
percent of clean claims submitted to the
organization, with respect to covered items or
services furnished to enrollees by a provider
of services or supplier, within the applicable
number of calendar days after the date of
initial receipt of such clean claim, regardless
of whether such items or services are furnished
under a contract between the organization and
the provider of services or supplier.
``(ii) Applicable number of calendar
days.--In clause (i), the term `applicable
number of calendar days' means--
``(I) in the case of a claim
submitted electronically, by a provider
of services or supplier for items or
services furnished under a contract
between the organization and the
provider of services or supplier, 14
days; and
``(II) in the case of a claim not
described in subclause (I), 30 days.
``(B) Clean claim defined.--In this paragraph, the
term `clean claim' means a claim that--
``(i) has a complete data set, with respect
to the UB-04 or CMS 1500 form, as applicable
(or successor to such applicable form), for all
entries identified as mandatory entries by the
National Uniform Billing Committee; and
``(ii) in the case of a claim submitted
electronically, is completed in accordance with
the applicable standards and data elements
adopted under section 1173(a).
``(C) Rebuttable presumption for receipt of
claim.--
``(i) In general.--For purposes of this
paragraph, there shall be a rebuttable
presumption that a claim has been received by
an MA organization--
``(I) in the case of a claim
submitted electronically, on the date
verified in the health care claim
status request and response transaction
that is for such claim and meets
applicable standards and data elements
adopted under section 1173(a) for such
electronic requests and responses; and
``(II) in the case of a claim
submitted otherwise, on the fifth
business day after the postmark date of
the claim or the date specified in the
time stamp of the transmission.
``(ii) Business day defined.--In clause
(i)(II), the term `business day' means any day
other than Saturday, Sunday, or a legal public
holiday described in section 6103 of title 5,
United States Code.
``(D) Interest applied for clean claims not
promptly paid.--If payment for such covered items or
services is not issued, mailed, or otherwise
transmitted to the provider of services or supplier for
such claims that are clean claims, in accordance with
subparagraph (A), by not later than the deadline for
such payment under such subparagraph, the MA
organization shall pay the provider of services or
supplier interest at the rate used for purposes of
section 3902(a) of title 31, United States Code
(relating to interest penalties for failure to make
prompt payments) for the period beginning on the day
after such required payment date and ending on the date
on which payment is made.''; and
(B) in subsection (g)--
(i) by redesignating paragraph (4) as
paragraph (5);
(ii) by inserting after paragraph (3) the
following new paragraph:
``(4) Application of civil money penalties to prompt pay
violations.--If the Secretary determines that an MA
organization with a contract under this section is not in
compliance with subsection (f)(1), the Secretary shall provide,
in addition to any other remedies authorized by law, for civil
money penalties of not more than $25,000 for each such
determination. In making a determination under the previous
sentence, the Secretary may take into account information
collected pursuant to section 1851(d)(4)(D)(v).''; and
(iii) in paragraph (5), as redesignated by
clause (i), by striking ``or (3)'' and
inserting ``, (3), or (4)''.
(2) Effective date.--The amendments made by this subsection
shall apply with respect to items and services furnished on or
after January 1, 2027, and contract years beginning on or after
such date.
(b) Provision of Information Regarding Compliance With Prompt
Payment Requirements.--Section 1851(d)(4)(D) of the Social Security Act
(42 U.S.C. 1395w-21(d)(4)(D)) is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) in clause (iv), by striking the period and inserting
``, and''; and
(3) by adding at the end the following new clause:
``(v) information regarding compliance of
the plan with the prompt payment requirements
under section 1857(f)(1), including, with
respect to the most recent 12-month period for
which data are available--
``(I) the number and percent of
submitted claims for which payment was
made by the plan;
``(II) the number and percent of
submitted claims--
``(aa) that were for items
or services furnished by a
provider of services or
supplier under a contract
between the organization
offering the plan and the
provider of services or
supplier; and
``(bb) that were for items
or services not furnished under
such a contract;
``(III) the number and percent of
submitted claims described in each of
items (aa) and (bb) of subclause (II)
for which payment was made by the plan
by the deadline required pursuant to
section 1857(f)(1)(A);
``(IV) the number and percent of
submitted claims described in each of
items (aa) and (bb) of subclause (II)
for which interest was paid by the plan
pursuant to section 1857(f)(1)(D); and
``(V) the total amount of interest
paid by the plan pursuant to such
section.''.
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