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HR 6109
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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.

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

Latest action (Nov 18, 2025) 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.

Referred to
Energy and Commerce Committee Ways and Means Committee
Policy area
Health
Issues
Healthcare

Summary

This bill amends Medicare law to establish standards for Medicare Advantage plans regarding reversed prior authorization coverage determinations. Starting one year after enactment, if a plan has more than 25 percent of initially denied prior authorizations later reversed upon reconsideration or appeal, the Centers for Medicare and Medicaid Services may terminate the plan's contract. The bill also allows contract termination if a plan has significantly fewer reversed determinations in a plan year compared to the previous year due to the plan's failure to appropriately reconsider denial determinations.

AI-generated plain-language summary of the bill text — neutral, and may be imperfect. See the full text below for the exact wording.

Sponsor (1)
18 cosponsors

Actions (2)
  1. Nov 18, 2025 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. · house
  2. Nov 18, 2025 Introduced in House

Similar bills (6)

Bills with similar text or summary — includes reintroductions across Congresses. Ranked by semantic similarity of the bill text (computed locally); a neutral discovery aid, not a claim the bills are duplicates.

  • HR 6110 — To amend title XVIII of the Social Security Act to require Medicare Advantage plans to automatically reconsider determinations denying coverage. · Introduced Nov 18, 2025 · Cong. 119 86%
  • HR 6111 — To amend title XVIII of the Social Security Act to require any advertisement of a Medicare Advantage plan to include information related to the rates of prior authorization denials under such plan. · Introduced Nov 18, 2025 · Cong. 119 79%
  • HR 6113 — To amend title XVIII of the Social Security Act to impose limitations on contracts with Medicare Advantage organizations offering multiple Medicare Advantage plans under the Medicare program. · Introduced Nov 18, 2025 · Cong. 119 76%
  • HR 6112 — To amend title XVIII of the Social Security Act to establish certain requirements with respect to the average monthly cost to provide coverage to an enrollee under Medicare Advantage plans. · Introduced Nov 18, 2025 · Cong. 119 75%
  • S 3762 — Prior Authorization Relief Act · Introduced Feb 3, 2026 · Cong. 119 73%
  • HR 3665 — Medicare Economic Security Solutions Act · Introduced May 29, 2025 · Cong. 119 72%

Text versions (1)
  • Introduced in House · Nov 18, 2025

Only one text version is on file, so there’s no earlier version to compare against yet.

Full text

IN THE HOUSE OF REPRESENTATIVES

November 18, 2025

Mr. Pocan (for himself, Mr. Carson, Mr. Cohen, Ms. DeLauro, Mr. Doggett, Ms. Jayapal, Mr. Khanna, Ms. Norton, Ms. Ocasio-Cortez, Ms. Schakowsky, Mr. Takano, Mr. Thanedar, Ms. Tlaib, Ms. Johnson of Texas, Ms. McBride, and Ms. Omar) 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 certain requirements with respect to rates of reversed prior authorization coverage determinations 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. ESTABLISHING REQUIREMENTS WITH RESPECT TO RATES OF REVERSED PRIOR AUTHORIZATION COVERAGE DETERMINATIONS UNDER MEDICARE ADVANTAGE PLANS.

Section 1857 of the Social Security Act (42 U.S.C. 1395w-27) is amended—

(1) in subsection (e), by adding at the end the following new paragraph:

“(6) Requirement on rates of reversed prior authorization coverage determinations.—

“(A) In general.—In the case of a Medicare Advantage plan that imposes any prior authorization requirement with respect to items or services furnished during a plan year beginning on or after the date that is 1 year after the date of the enactment of this paragraph, if the Secretary determines that such plan exceeds the allowable rate of reversed prior authorization coverage determinations under subparagraph (B) with respect to such plan year, the Secretary shall terminate the contract with respect to the offering of such plan under this section.

“(B) Allowable rate of reversed prior authorization coverage determinations.—For purposes of subparagraph (A), a Medicare Advantage plan exceeds the allowable rate of reversed prior authorization coverage determinations under this subparagraph with respect to a plan year if—

“(i) greater than 25 percent of prior authorization coverage determinations made during such plan year initially deny coverage and are later—

“(I) reconsidered and reversed pursuant to section 1852(g)(2); or

“(II) appealed and reversed pursuant to section 1852(g)(5); or

“(ii) the Secretary determines that—

“(I) significantly fewer prior authorization coverage determinations made during such plan year that are reconsidered pursuant to section 1852(g)(2) are reversed, as compared to the number of such determinations made during the previous plan year that are so reconsidered and reversed; and

“(II) the reduction in the number of reconsidered and reversed prior authorization coverage determinations described in subclause (I) occurred because the Medicare Advantage organization that offers such plan failed to appropriately reconsider prior authorization coverage determinations made during such plan year pursuant to section 1852(g)(2).

“(C) Prior authorization coverage determination defined.—In this paragraph, the term ‘prior authorization coverage determination’ means, with respect to a Medicare Advantage plan, a coverage determination made under section 1852(g) regarding whether an individual enrolled in such plan is entitled to receive an item or service under the prior authorization requirement imposed under such plan with respect to such item or service.”; and

(2) in subsection (h)(1)(A), by inserting “except in the case of a termination of a contract due to failure to meet the requirement under subsection (e)(6),” before “the Secretary”. <all>

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