Congress tightens Medicare Advantage rules: faster approvals, public scorecards, payment penalties
H.R. 8375 — Medicare Advantage Improvement Act of 2026 · Filed by John Joyce (R-PA) · 23 cosponsors · Introduced Apr 20, 2026 · Referred to committee
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What it does
This bill tightens Medicare Advantage (MA) plan rules to speed up authorization decisions, improve transparency, and penalize insurers for non-compliance. Starting in 2028, MA plans must approve or deny coverage requests within 72 hours (24 hours for urgent cases), publish prior authorization data publicly, and provide real-time approvals for routine services. Plans that fail compliance audits face payment cuts of 1–2%, and they cannot retroactively deny or downcode claims once approved. The bill also requires MA plans to use the same medical necessity standards as traditional Medicare and restricts their use of third-party review companies.
Why we flagged it
The bill is fundamentally a regulatory enforcement and transparency measure targeting Medicare Advantage insurers. It imposes new operational requirements (faster decisions, real-time approvals), compliance scoring with financial penalties, and data disclosure mandates. It is not a subsidy, carve-out, or commemorative measure.
What the text implies
- Compliance scoring system (1–4 tiers) creates a new regulatory enforcement lever; plans scoring below 60 face 2% payment cuts, which may incentivize approval of borderline claims to avoid penalties.
- Real-time authorization requirement for high-approval-rate services may shift burden to providers to integrate with MA EHR systems; smaller practices may struggle with interoperability costs.
The full analysis lists 5 implications of this text.
Who stands to gain
Healthcare providers (hospitals, physicians, post-acute care facilities); Medicare Advantage enrollees (faster approvals, stronger protections); Independent review entities (expanded appeals workload)