H.R. 8375: Medicare Advantage Improvement Act of 2026

The Medicare Advantage Improvement Act of 2026 is designed to reform the Medicare Advantage program, focusing on enhancing access to care and improving the overall efficiency and transparency of the program. The bill proposes several key changes, including:

Access to Care

The bill seeks to improve access to medical care for beneficiaries of the Medicare Advantage program. This is aimed at ensuring that individuals enrolled have better opportunities to receive the healthcare services they need without unnecessary barriers.

Authorization Processes

One of the significant features of this bill is the implementation of real-time authorization decisions. This means that requests for care will be processed more quickly, allowing for faster access to necessary treatments. This change is intended to reduce waiting times for patients and enhance the efficiency of the authorization process.

Transparency and Compliance

To promote transparency, the bill mandates that Medicare Advantage organizations (MAOs) disclose their coverage criteria. It is important that the criteria for approving services are not more restrictive than those used by traditional Medicare. This change will take effect for services provided after January 1, 2028.

Automation of Payments

The bill also addresses the claims payment process by establishing automated systems for handling claims. This is expected to streamline operations and eliminate inefficiencies in how payments are made for services rendered under the Medicare Advantage program.

Oversight of Medicare Advantage Organizations

Stricter oversight measures will be implemented to ensure that Medicare Advantage organizations comply with the new standards set forth in the legislation. This includes ongoing monitoring to assess compliance and quality of care standards.

Amendments to the Social Security Act

The bill amends the Social Security Act to enforce that the medical necessity criteria used by Medicare Advantage organizations do not impose more stringent requirements than those in traditional Medicare. This aims to standardize the benchmarking of care and ensure beneficiaries receive equitable treatment regardless of the program.

Implementation Timeline

The changes proposed by the bill are set to be phased in, with specific provisions like the application of non-restrictive medical necessity criteria taking effect on January 1, 2028.

Summary of Objectives

• Enhance access to healthcare for Medicare Advantage beneficiaries.
• Introduce real-time decision-making for care authorizations.
• Ensure transparency in coverage and adherence to equitable standards.
• Improve efficiency in claims processing through automation.
• Implement stricter compliance measures for Medicare Advantage organizations.

Relevant Companies

• CNC - Centene Corporation may be impacted by the reforms in authorization processes and transparency requirements.
• HUM - Humana Inc. could see changes in operational practices due to the new compliance measures.
• UNH - UnitedHealth Group may need to adjust their policies in line with the non-restrictive criteria mandated by the bill.