119-HR-6109 Journalist Public Summary

Headline Summary

A crackdown on Medicare Advantage prior authorization: if a plan reverses too many initial denials, the government must terminate its contract.

What It Does

The bill targets prior authorization denials that are later overturned. If, in a plan year, more than 25% of all prior-authorization coverage determinations start as denials and are later reversed on reconsideration or appeal, the Secretary of Health and Human Services must terminate that plan’s Medicare Advantage contract. It also tries to prevent gaming by allowing termination if a plan appears to depress reversal counts by failing to appropriately reconsider cases. The bill clarifies that this kind of termination is treated differently from standard non‑renewals.

Why It Matters

Reversals usually mean care was delayed despite ultimately being approved. In 2023, most appealed Medicare Advantage prior-authorization denials were overturned, underscoring concerns about inaccurate initial denials; at the same time, only a small share of denials are appealed. [1]KFF — Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization De…

Federal watchdogs have also found inappropriate denials that would have been covered under traditional Medicare, which can delay medically necessary care. [3]HHS OIG — Some Medicare Advantage Organization Denials of Prior Authorization R…

Separately, CMS and insurers have been moving to streamline prior authorization (more electronic submissions, faster timelines), but those efforts don’t directly penalize high reversal rates—this bill would. [4]Centers for Medicare & Medicaid Services — CMS Interoperability and Prior Autho…[2]AHIP — Health Plans Take Action to Simplify Prior Authorization

Who’s For It

• Sponsor: Rep. Mark Pocan (D‑WI). Co‑sponsors listed in the filing include Reps. André Carson, Steve Cohen, Rosa DeLauro, Lloyd Doggett, Pramila Jayapal, Ro Khanna, Eleanor Holmes Norton, Alexandria Ocasio‑Cortez, Jan Schakowsky, Mark Takano, Shri Thanedar, Rashida Tlaib, Julie Johnson (TX), Sarah McBride, and Ilhan Omar.
• Many patient advocates and physician groups have broadly supported tightening oversight of MA prior authorization, citing delays and high overturn rates on appeal (not specific to this bill). [1]KFF — Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization De…[3]HHS OIG — Some Medicare Advantage Organization Denials of Prior Authorization R…

Who’s Against It

• Potential opposition: Medicare Advantage insurers and allied trade groups. They have favored streamlining and standardizing prior authorization rather than punitive thresholds that could trigger contract termination. [2]AHIP — Health Plans Take Action to Simplify Prior Authorization
• Context: Insurers recently pledged voluntary reforms (more electronic approvals, fewer required authorizations), suggesting they may argue penalties are unnecessary or could encourage rubber‑stamping. [5]Reuters — Health insurers to work on easing prior authorization requirements, A…

What’s Next

As of November 18, 2025, the bill has been introduced in the House and referred to the Ways and Means Committee and the Energy and Commerce Committee. Next steps would typically include hearings, committee markups, and, if advanced, a House floor vote, followed by Senate consideration. (Status may change as committees act.)

Notes and Trade‑offs

Tone

Neutral, plain‑English, and focused on what the bill says and how it could affect patients, providers, and plans.