A bipartisan group of U.S. representatives and senators, many of whom are doctors, have written a prescription for Medicare Advantage (MA) reform through the newly-introduced Medicare Advantage Improvement Act of 2026 (HR 8375/S 4384).

The effort is led by Congressman John Joyce (R-PA) and includes Reps. Kim Schrier (D-WA), Greg Murphy (R-NC), Jimmy Panetta (D-CA) Ami Bera (D-CA), Mariannette Miller-Meeks (R-IA), and Beth Van Duyne (R- TX) as co-sponsors of the House version of the legislation, which was introduced on April 22, 2026. Senators Roger Marshall (R-KS) and Sheldon Whitehouse (R-RI) introduced a similar bill on April 27.

Overall, the bill seeks to address prior authorization delays, service delays, payment claw backs, and prompt-pay issues, and proposes a new approach to MA plan accountability and oversight.

To improve timely access to care and services for MA enrollees, the bill proposes to reduce the time that MA organizations (MAOs) have to make prior authorization decisions to no more than 72 hours for standard requests (currently 7 calendar days) and no more than 24 hours for expedited requests (currently 72 hours). In 2025, LeadingAge and its Post Acute Care Medicare Advantage (PAC MA) Coalition partners asked the Centers for Medicare and Medicaid Services (CMS) to adopt the 24-hour expedited timeline and establish all PAC prior authorization requests as expedited. CMs has not yet taken this step.

The bill would also require CMS to annually establish a list of services considered routine, low-risk or high volume that would be subject to real-time, automated approvals by the MAOs. Additionally, the bill would prohibit MAOs from using algorithms to automatically deny requests. For denials that are appealed, the bill would require the MAO to submit denial affirmations to the independent review entities within 14 days, instead of the current 60 days.

LeadingAge members have articulated ongoing frustration with MA claims processing practices where some MAOs delay notifying them about the status of a claim until near the timely filing deadline making it difficult to correct any defects and be paid  promptly. The MA Improvement Act would require MAOs to automatically treat a claim for an authorized service as a clean claim and pay 100% of these claims promptly. Further, it would prohibit plans from denying coverage or downgrading codes after the MAO grants a prior authorization, except in situation where there is fraud or a clear error.

The bill would also place limits on MAO’s use of third party entities to conduct post-claim reviews. Additionally, plans would also be required to establish an automated payment proccess that would require clean claims for authorized services to be processed paid automatically. Plans would also exclude such claims from being subject to a manual claim review unless there is evidence of fraud, potentially reducing provider audits and administrative burden.

The bill also envisions an entirely new approach to MAO regulatory compliance and oversight by requiring the Secretary of Health and Human Services establish a compliance scoring system and using that system to assess mandatory, tiered penalties of up to 2% to plans who don’t achieve at least a 90% compliance score. In addition, it would also require a new “Compliance and Coverage Protection” domain be added to the MA star rating system. This domain would be more heavily weight the all the other Star Rating measures.

The compliance categories that have to be considered in developing the score include compliance with:

• Timely and real-time specified authorization decisions
• Coverage criteria standards
• Prompt payment requirements
• Restrictions on improper retroactive denials and downgrades
• Marketing, enrollment, and beneficiary communication requirements

Adding this domain could have a material impact on MA plan payments from how benchmarks are set, to eligibility for up to a 5% quality bonus and how much a rebate they receive to cover supplemental benefits.

Overall, the bills’ provisions would be scheduled to take effect on January 1, 2028, if enacted.

LeadingAge thinks the bill has many merits and warrants our support. However, questions remain. We will be seeking clarification on some of its provisions to ensure the bill’s intent is achieved and improves timely access to care for beneficiaries and timely payment and less administrative burden for providers.

We will be discussing the legislation in more detail at our upcoming May 14 Managed Care Solutions Network at 3 p.m. ET to get member reaction to the bill.  Members who wish to join this or future meetings can register here to join the network and receive communications about the agenda and Zoom details.