[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10394 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 10394
To amend title XVIII of the Social Security Act to establish
requirements with respect to the use of prior authorization and claims
denial under Medicare Advantage plans.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 15, 2026
Mr. Landsman (for himself and Mr. Onder) introduced the following bill;
which was referred to the Committee on Ways and Means, and in addition
to the Committee on Energy and Commerce, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to establish
requirements with respect to the use of prior authorization and claims
denial under Medicare Advantage plans.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Protecting Approved Care Act''.
SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR
AUTHORIZATION AND CLAIMS DENIAL UNDER MEDICARE ADVANTAGE
PLAN.
Section 1857(e) of the Social Security Act (42 U.S.C. 1395e-27(e))
is amended by adding at the end the following new paragraph:
``(7) Limitations on claims denial for covered items and
services.--
``(A) In general.--Beginning with plan years
beginning on or after January 1, 2028, a contract under
this section with an MA organization shall require
that--
``(i) in the case that the MA organization
approves the furnishing to an individual
enrolled under an MA plan offered by such MA
organization of an item or service through a
specified authorization made during the receipt
by the individual of such item or service, the
MA organization may not, after such approval,
take any of the actions described in
subparagraph (B) with respect to such item or
service; and
``(ii) in the case that there is no
requirement to obtain a specified authorization
with respect to an item or service for which
benefits are available under the plan, the MA
organization may not, after an individual
enrolled under such plan receives such item or
service, take any of the actions described in
subparagraph (B) with respect to such item or
service.
``(B) Actions described.--For purposes of
subparagraph (A), the actions described in this
subparagraph are, with respect to an MA organization
and an item or service, the following:
``(i) Denying coverage of such item or
service on the basis of lack of medical
necessity.
``(ii) Reopening a determination of
coverage or payment made with respect to such
item or service (including a specified
authorization) for any reason other than--
``(I) good cause (as described in
sections 405.986 and 422.616 of title
42, Code of Federal Regulations (or any
successor regulation)); or
``(II) reliable evidence of fraud
or similar fault (as such terms are
defined in section 405.902 of such
title (or any successor regulation)),
as determined in accordance with
section 422.616 of such title (or any
successor regulation).
``(iii) Changing the code assigned with
respect to the claim for such item or service
such that the amount of payment for such claim
would be reduced, except for good cause (as
described in clause (ii)) or if there is
reliable evidence of fraud or similar fault (as
so described).
``(C) Specified authorization defined.--In this
paragraph, the term `specified authorization'--
``(i) means, with respect to an individual
enrolled under an MA plan offered by a Medicare
Advantage organization, an authorization of
coverage or payment for an item or service
through--
``(I) a prior authorization or
preservice determination of coverage or
payment; or
``(II) a concurrent determination
made while the individual is receiving
the relevant item or service; and
``(ii) includes an authorization for a
transfer of the individual between hospitals or
between a hospital and post-acute care
facility.''.
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