[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6109 Introduced in House (IH)]

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119th CONGRESS
  1st Session
                                H. R. 6109

 To amend title XVIII of the Social Security Act to establish certain 
  requirements with respect to rates of reversed prior authorization 
        coverage determinations under Medicare Advantage plans.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           November 18, 2025

    Mr. Pocan (for himself, Mr. Carson, Mr. Cohen, Ms. DeLauro, Mr. 
 Doggett, Ms. Jayapal, Mr. Khanna, Ms. Norton, Ms. Ocasio-Cortez, Ms. 
Schakowsky, Mr. Takano, Mr. Thanedar, Ms. Tlaib, Ms. Johnson of Texas, 
  Ms. McBride, and Ms. Omar) 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 certain 
  requirements with respect to rates of reversed prior authorization 
        coverage determinations under Medicare Advantage plans.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. ESTABLISHING REQUIREMENTS WITH RESPECT TO RATES OF REVERSED 
              PRIOR AUTHORIZATION COVERAGE DETERMINATIONS UNDER 
              MEDICARE ADVANTAGE PLANS.

    Section 1857 of the Social Security Act (42 U.S.C. 1395w-27) is 
amended--
            (1) in subsection (e), by adding at the end the following 
        new paragraph:
            ``(6) Requirement on rates of reversed prior authorization 
        coverage determinations.--
                    ``(A) In general.--In the case of a Medicare 
                Advantage plan that imposes any prior authorization 
                requirement with respect to items or services furnished 
                during a plan year beginning on or after the date that 
                is 1 year after the date of the enactment of this 
                paragraph, if the Secretary determines that such plan 
                exceeds the allowable rate of reversed prior 
                authorization coverage determinations under 
                subparagraph (B) with respect to such plan year, the 
                Secretary shall terminate the contract with respect to 
                the offering of such plan under this section.
                    ``(B) Allowable rate of reversed prior 
                authorization coverage determinations.--For purposes of 
                subparagraph (A), a Medicare Advantage plan exceeds the 
                allowable rate of reversed prior authorization coverage 
                determinations under this subparagraph with respect to 
                a plan year if--
                            ``(i) greater than 25 percent of prior 
                        authorization coverage determinations made 
                        during such plan year initially deny coverage 
                        and are later--
                                    ``(I) reconsidered and reversed 
                                pursuant to section 1852(g)(2); or
                                    ``(II) appealed and reversed 
                                pursuant to section 1852(g)(5); or
                            ``(ii) the Secretary determines that--
                                    ``(I) significantly fewer prior 
                                authorization coverage determinations 
                                made during such plan year that are 
                                reconsidered pursuant to section 
                                1852(g)(2) are reversed, as compared to 
                                the number of such determinations made 
                                during the previous plan year that are 
                                so reconsidered and reversed; and
                                    ``(II) the reduction in the number 
                                of reconsidered and reversed prior 
                                authorization coverage determinations 
                                described in subclause (I) occurred 
                                because the Medicare Advantage 
                                organization that offers such plan 
                                failed to appropriately reconsider 
                                prior authorization coverage 
                                determinations made during such plan 
                                year pursuant to section 1852(g)(2).
                    ``(C) Prior authorization coverage determination 
                defined.--In this paragraph, the term `prior 
                authorization coverage determination' means, with 
                respect to a Medicare Advantage plan, a coverage 
                determination made under section 1852(g) regarding 
                whether an individual enrolled in such plan is entitled 
                to receive an item or service under the prior 
                authorization requirement imposed under such plan with 
                respect to such item or service.''; and
            (2) in subsection (h)(1)(A), by inserting ``except in the 
        case of a termination of a contract due to failure to meet the 
        requirement under subsection (e)(6),'' before ``the 
        Secretary''.
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