Medicare crackdown: Plans that deny care too often face contract termination
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. · Filed by Mark Pocan (D-WI) · 18 cosponsors · Introduced Nov 18, 2025 · Referred to committee
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What it does
This bill amends Medicare Advantage rules to penalize insurance plans that deny coverage too often and then reverse those denials on appeal. If more than 25% of a plan's initial prior authorization denials are later overturned through reconsideration or appeal, or if a plan significantly reduces its reconsideration rate year-over-year, the Centers for Medicare & Medicaid Services (CMS) can terminate the plan's contract. The goal is to reduce unnecessary coverage denials that force patients to appeal to get care they should have received initially.
Why we flagged it
The bill's core function is to establish enforceable standards against systematic coverage denials in Medicare Advantage plans, using contract termination as a deterrent. It is consumer-protection legislation, not a subsidy or carve-out.
What the text implies
- Plans may respond by tightening initial approval criteria to avoid the 25% reversal threshold, potentially shifting denial patterns rather than reducing them overall.
- The 25% threshold is a bright-line rule; plans just below it face no penalty, creating a perverse incentive to optimize denials at exactly 24.9%.
The full analysis lists 4 implications of this text.
Who stands to gain
Medicare beneficiaries (reduced out-of-pocket costs from fewer wrongful denials); Healthcare providers (fewer appeals to process, faster payment authorization)