Medicare Advantage: New Rules to Limit Denials and Protect Patient Access.
This bill establishes strict penalties for Medicare Advantage (MA) plans that frequently deny coverage requests which are later overturned upon appeal or reconsideration. If an MA plan's rate of reversed prior authorization denials exceeds 25%, the government must terminate its contract. This measure aims to reduce unnecessary delays and administrative burdens for patients seeking essential medical services.
Key points
MA plans must correctly approve necessary medical services upfront to avoid penalties.
If more than 25% of initial prior authorization denials are later reversed, the plan faces contract termination.
The rule is designed to ensure patients receive timely access to approved care without excessive appeals.
Introduced
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