Loading…
Sponsored byGreg Landsman+5 co-sponsors
Last updated Sep 15, 2026 · Federal · Source: LegiScan ↗
The Protecting Approved Care Act amends Medicare law to restrict Medicare Advantage plans from denying claims or reversing coverage decisions after they have approved an item or service via prior authorization or after the service has already been provided to the enrollee. It limits post-approval claim denials for lack of medical necessity, restricts reopening of determinations, and prohibits downcoding that reduces payment except in cases of good cause or proven fraud.
I 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. O NDER ) introduced the following bill; which was referred to the Committee on Ways and Means, and in addi- tion to the Committee on Energy and Commerce, for a period to be sub- sequently 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 authoriza- tion and claims denial under Medicare Advantage plans. Be it enacted by the Senate and House of Representa-1 tives of the United States of America in Congress assembled,2 SECTION 1. SHORT TITLE.3 This Act may be cited as the ‘‘Protecting Approved4 Care Act’’.5 VerDate Sep 11 2014 00:10 Sep 17, 2026 Jkt 069200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H10394.IH H10394 ssavage on LAPJG3WLY3PROD with BILLS 2 •HR 10394 IH SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO1 THE USE OF PRIOR AUTHORIZATION AND2 CLAIMS DENIAL UNDER MEDICARE ADVAN-3 TAGE PLAN.4 Section 1857(e) of the Social Security Act (42 U.S.C.5 1395e–27(e)) is amended by adding at the end the fol-6 lowing new paragraph:7 ‘‘(7) LIMITATIONS ON CLAIMS DENIAL FOR COV -8 ERED ITEMS AND SERVICES .—9 ‘‘(A) IN GENERAL .—Beginning with plan10 years beginning on or after January 1, 2028, a11 contract under this section with an MA organi-12 zation shall require that—13 ‘‘(i) in the case that the MA organiza-14 tion approves the furnishing to an indi-15 vidual enrolled under an MA plan offered16 by such MA organization of an item or17 service through a specified authorization18 made during the receipt by the individual19 of such item or service, the MA organiza-20 tion may not, after such approval, take any21 of the actions described in subparagraph22 (B) with respect to such item or service;23 and24 ‘‘(ii) in the case that there is no re-25 quirement to obtain a specified authoriza-26 VerDate Sep 11 2014 00:10 Sep 17, 2026 Jkt 069200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H10394.IH H10394 ssavage on LAPJG3WLY3PROD with BILLS 3 •HR 10394 IH tion with respect to an item or service for1 which benefits are available under the2 plan, the MA organization may not, after3 an individual enrolled under such plan re-4 ceives such item or service, take any of the5 actions described in subparagraph (B) with6 respect to such item or service.7 ‘‘(B) ACTIONS DESCRIBED .—For purposes8 of subparagraph (A), the actions described in9 this subparagraph are, with respect to an MA10 organization and an item or service, the fol-11 lowing:12 ‘‘(i) Denying coverage of such item or13 service on the basis of lack of medical ne-14 cessity.15 ‘‘(ii) Reopening a determination of16 coverage or payment made with respect to17 such item or service (including a specified18 authorization) for any reason other than—19 ‘‘(I) good cause (as described in20 sections 405.986 and 422.616 of title21 42, Code of Federal Regulations (or22 any successor regulation)); or23 ‘‘(II) reliable evidence of fraud or24 similar fault (as such terms are de-25 VerDate Sep 11 2014 00:10 Sep 17, 2026 Jkt 069200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H10394.IH H10394 ssavage on LAPJG3WLY3PROD with BILLS 4 •HR 10394 IH fined in section 405.902 of such title1 (or any successor regulation)), as de-2 termined in accordance with section3 422.616 of such title (or any suc-4 cessor regulation).5 ‘‘(iii) Changing the code assigned with6 respect to the claim for such item or serv-7 ice such that the amount of payment for8 such claim would be reduced, except for9 good cause (as described in clause (ii)) or10 if there is reliable evidence of fraud or11 similar fault (as so described).12 ‘‘(C) SPECIFIED AUTHORIZATION DE -13 FINED .—In this paragraph, the term ‘specified14 authorization’—15 ‘‘(i) means, with respect to an indi-16 vidual enrolled under an MA plan offered17 by a Medicare Advantage organization, an18 authorization of coverage or payment for19 an item or service through—20 ‘‘(I) a prior authorization or21 preservice determination of coverage22 or payment; or23 VerDate Sep 11 2014 00:10 Sep 17, 2026 Jkt 069200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H10394.IH H10394 ssavage on LAPJG3WLY3PROD with BILLS 5 •HR 10394 IH ‘‘(II) a concurrent determination1 made while the individual is receiving2 the relevant item or service; and3 ‘‘(ii) includes an authorization for a4 transfer of the individual between hospitals5 or between a hospital and post-acute care6 facility.’’.7 Æ VerDate Sep 11 2014 00:10 Sep 17, 2026 Jkt 069200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6301 E:\BILLS\H10394.IH H10394 ssavage on LAPJG3WLY3PROD with BILLS
A plain-language summary of what this bill would mean for your issues is being prepared.
This bill affects Healthcare.
Create a free account and set your issue preferences to see your alignment.
Sign Up for free →No roll-call vote has been recorded for this bill yet.
Want to dig deeper?
Create a free account to see your alignment for every bill — then Pro unlocks full voting history and AI analysis.
Sign Up for freeThe governor or the President signs the bill, vetoes it, or lets it become law without a signature. A legislature can also override a veto and enact the bill anyway.
Not recorded. That means we hold nothing showing this step, not that it did not happen.
Stages, sponsors and executive actions are read from the legislature's own published record via LegiScan. We report what it says and never infer an action from a date alone.