Bill > HR6109

This bill proposes to establish new requirements for Medicare Advantage (MA) plans regarding their prior authorization coverage determinations. Specifically, the bill would require the Secretary of Health and Human Services to terminate a Medicare Advantage plan's contract if the plan exceeds certain thresholds for reversing prior authorization decisions. Under the proposed requirements, a plan would be at risk of contract termination if more than 25 percent of its prior authorization coverage determinations are initially denied and then later reversed through reconsideration or appeal, or if the Secretary determines that the plan has significantly reduced its rate of reversing prior authorization decisions compared to the previous year, potentially due to inappropriate reconsideration practices. A prior authorization coverage determination is defined as a decision made under an MA plan about whether an enrolled individual is entitled to receive a specific item or service before it is provided. The goal of this bill appears to be ensuring that Medicare Advantage plans are not inappropriately denying coverage for medical services that are ultimately deemed necessary upon review, thereby protecting patients' access to needed healthcare.

Budget and Finance

https://www.congress.gov/bill/119th-congress/house-bill/6109/all-info