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HR 6109119th CongressIn Committee
To amend title XVIII of the Social Security Act to establish certain requirements with respect to rates of reversed prior authorization coverage determinations under Medicare Advantage plans.
Introduced: Nov 18, 2025
Sponsor: Rep. Pocan, Mark [D-WI-2] (D-Wisconsin)
Standard Summary
Comprehensive overview in 1-2 paragraphs
A bill amending Title XVIII of the Social Security Act to set thresholds for the rate of reversed prior‑authorization coverage determinations, with enforcement that may terminate contracts for Medicare Advantage plans that exceed the allowable rate.
Key Points
- 1Definition of reversed prior‑authorization coverage determinations
- 2Threshold: >25 % of denied requests reversed or appealed
- 3Enforcement: Secretary may terminate contracts if threshold exceeded
- 4Consideration of significant differences in premiums or benefits
- 5Protection of enrollees from excessive denial reversals
Impact Areas
Medicare Advantage plansEnrollees and beneficiariesHealthcare providersMedicare program administration
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