I 
119TH CONGRESS 
1ST SESSION H. R. 4559 
To amend title XVIII of the Social Security Act to establish payment parity 
between Medicare Advantage and fee-for-service Medicare, and to estab-
lish prompt payment requirements under Medicare Advantage. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 21, 2025 
Mr. DOGGETT (for himself and Mr. MURPHY) 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 
payment parity between Medicare Advantage and fee- 
for-service Medicare, and to establish prompt payment 
requirements under Medicare Advantage. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Prompt and Fair Pay 
Act’’. 
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SEC. 2. ESTABLISHING PAYMENT PARITY BETWEEN MEDI-
CARE ADVANTAGE AND FEE-FOR-SERVICE 
MEDICARE. 
Section 1857(e) of the Social Security Act (42 U.S.C. 
1395w–27(e)) is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(6) PAYMENT PARITY WITH FEE-FOR-SERVICE 
MEDICARE.—Beginning with plan years beginning 
on or after January 1, 2027, a contract under this 
part shall require an MA organization to provide, in 
any contract between the organization and a pro-
vider or supplier, that payment for items and serv-
ices furnished to an enrollee by such provider or 
supplier shall be in an amount that is not less than 
the amount of payment applicable on the date of 
service for such items and services under the original 
Medicare fee-for-service program under parts A and 
B, including cost-based payment methodologies.’’. 
SEC. 3. PROTECTING BENEFICIARY ACCESS TO CARE 
UNDER MEDICARE ADVANTAGE BY ESTAB-
LISHING ENFORCEABLE PROMPT PAYMENT 
REQUIREMENTS 
AND 
ENHANCING 
TRANS-
PARENCY REGARDING CLAIMS DENIALS. 
(a) APPLYING PROMPT PAYMENT REQUIREMENTS 
FOR ITEMS AND SERVICES FURNISHED BY IN-NETWORK 
PROVIDERS.— 
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(1) IN GENERAL.—Section 1857(f) of the Social 
Security Act (42 U.S.C. 1395w–27(f)) is amended— 
(A) in paragraph (1), in the header, by in-
serting ‘‘APPLICABLE WITH RESPECT TO OUT- 
OF-NETWORK
PROVIDERS
OF
SERVICES
AND 
SUPPLIERS’’ after ‘‘REQUIREMENT’’; 
(B) in paragraph (2), by striking ‘‘compli-
ance with paragraph (1)’’ and inserting ‘‘com-
pliance with paragraph (1) or (2)’’; 
(C) by redesignating paragraphs (2) and 
(3) as paragraphs (3) and (4), respectively; and 
(D) by inserting after paragraph (1) the 
following new paragraph: 
‘‘(2) REQUIREMENT
APPLICABLE
WITH
RE-
SPECT
TO
IN-NETWORK
PROVIDERS
OF
SERVICES 
AND SUPPLIERS.— 
‘‘(A) 
PROMPT
PAYMENT
OF
CLEAN 
CLAIMS.— 
‘‘(i) IN GENERAL.—For contract years 
beginning on or after January 1, 2027, a 
contract entered into with an MA organi-
zation with respect to offering an MA plan 
under this part shall require that contracts 
and other agreements between such MA 
organization and providers of services and 
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suppliers to furnish items and services to 
enrollees under such plan shall provide 
that payment shall, in accordance with the 
provisions of this paragraph, be issued, 
mailed, or otherwise transmitted, with re-
spect to all clean claims submitted for such 
items and services furnished by such pro-
viders of services and suppliers to such en-
rollees, by not later than the applicable 
number of calendar days (as defined in 
clause (iii)) after the date on which the 
claim is received (as determined in accord-
ance with clause (ii)). 
‘‘(ii) DATE OF RECEIPT OF CLAIM.— 
For purposes of this paragraph, a claim is 
considered to have been received— 
‘‘(I) with respect to claims sub-
mitted electronically, on the date on 
which the claim is transferred; and 
‘‘(II) with respect to claims sub-
mitted otherwise, on the 5th day after 
the postmark date of the claim or the 
date specified in the time stamp of 
transmission. 
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‘‘(iii) APPLICABLE NUMBER OF CAL-
ENDAR DAYS DEFINED.—For purposes of 
this paragraph, the term ‘applicable num-
ber of calendar days’ means— 
‘‘(I) with respect to claims sub-
mitted electronically, 14 days; and 
‘‘(II) with respect to claims sub-
mitted otherwise, 30 days. 
‘‘(B) PROCEDURES AND RULES FOR DE-
TERMINING
WHETHER
CLAIMS
ARE
CLEAN 
CLAIMS.— 
‘‘(i) CLEAN CLAIM DEFINED.—In this 
paragraph, the term ‘clean claim’ means— 
‘‘(I) a claim that has no defect or 
impropriety (including any lack of any 
required substantiating documenta-
tion) or particular circumstance re-
quiring special treatment that pre-
vents timely payment from being 
made on the claim under this part; 
and 
‘‘(II) a claim that otherwise con-
forms to the clean claim requirements 
for equivalent claims under original 
Medicare. 
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‘‘(ii) CLAIM
DEEMED
TO
BE
CLEAN 
WHEN
TIMELY
NOTICE
OF
ANY
DEFI-
CIENCY IS NOT PROVIDED.—For purposes 
of this paragraph, with respect to an MA 
organization and a provider of services or 
supplier with whom the MA organization 
has a contract to furnish items and serv-
ices, a claim for such items and services 
furnished by such provider of services or 
supplier under such contract shall be 
deemed to be a clean claim if the MA orga-
nization does not provide notice to the pro-
vider of services or supplier of any defi-
ciency in the claim— 
‘‘(I) with respect to claims sub-
mitted electronically, within 10 days 
after the date on which the claim is 
received; and 
‘‘(II) with respect to claims sub-
mitted otherwise, within 15 days after 
the date on which the claim is re-
ceived. 
‘‘(iii) REQUIRED NOTIFICATIONS AND 
TREATMENT OF CLAIMS INITIALLY DETER-
MINED TO NOT BE CLEAN CLAIMS.—For 
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purposes of this paragraph, with respect to 
an MA organization and a provider of serv-
ices or supplier with whom the MA organi-
zation has a contract to furnish items and 
services— 
‘‘(I) if the MA organization de-
termines that a submitted claim for 
such items and services furnished by 
such provider of services or supplier 
under such contract is not a clean 
claim, the MA organization shall, not 
later than the end of the applicable 
period described in clause (ii), notify 
the provider of services or supplier of 
such determination and in such notifi-
cation shall specify all defects or im-
proprieties in the claim and shall list 
all additional information or docu-
ments necessary for the proper proc-
essing and payment of the claim, in-
cluding detailed instructions for re-
submission of claims, how to address 
each specified defect or impropriety, 
any formatting or coding guidance 
specific to the rejection reason, and 
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how to contact the plan to obtain as-
sistance with resubmission; and 
‘‘(II) in the case in which addi-
tional information is received pursu-
ant to a notification under subclause 
(I) with respect to a claim described 
in such subclause, the claim shall be 
deemed to be a clean claim described 
in clause (i) if the MA organization 
does not provide notice to the provider 
of service or supplier of any defect or 
impropriety in the claim not later 
than 10 days of the date on which 
such additional information is re-
ceived. 
‘‘(iv) RULE
OF
CONSTRUCTION.—A 
determination under this paragraph that a 
claim submitted by a provider of services 
or supplier is a clean claim shall not be 
construed as a positive determination re-
garding eligibility for payment under this 
title, nor is it an indication of government 
approval of, or acquiescence regarding, the 
claim submitted. The determination shall 
not relieve any party of civil or criminal li-
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ability with respect to the claim, nor does 
it offer a defense to any administrative, 
civil, or criminal action with respect to the 
claim. 
‘‘(C) OBLIGATION TO PAY.—For purposes 
of this paragraph: 
‘‘(i) IN GENERAL.—A claim submitted 
to an MA organization that is not paid or 
contested by the organization within the 
applicable number of calendar days (as de-
fined in subparagraph (A)(iii)) after the 
date on which the claim is received (as de-
termined in accordance with subparagraph 
(A)(ii)) shall be deemed to be a clean claim 
and shall be paid by the MA organization 
in accordance with subparagraph (A)(i). 
‘‘(ii) 
ELECTRONIC
TRANSFER
OF 
FUNDS.—An MA organization shall pay all 
clean claims submitted electronically by 
electronic transfer of funds if the provider 
of services or supplier so requests or has so 
requested previously. In the case in which 
such payment is made electronically, remit-
tance may be made by the MA organiza-
tion electronically as well. 
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‘‘(iii) DATE OF PAYMENT OF CLAIM.— 
Payment of a clean claim under this para-
graph shall be considered to have been 
made on the date on which— 
‘‘(I) with respect to claims paid 
electronically, the payment is trans-
ferred; and 
‘‘(II) with respect to claims paid 
otherwise, the payment is submitted 
to the United States Postal Service or 
common carrier for delivery. 
‘‘(D) INTEREST PAYMENT.— 
‘‘(i) For purposes of this paragraph, 
subject to clause (ii), if payment is not 
issued, mailed, or otherwise transmitted 
within the applicable number of calendar 
days (as defined in subparagraph (A)(iii)) 
after a clean claim (with respect to which 
this paragraph applies) is received, the MA 
organization shall pay interest to the pro-
vider of services or supplier that submitted 
the claim at a rate equal to the weighted 
average of interest on 3-month marketable 
Treasury securities determined for such 
period, increased by 0.1 percentage point 
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for the period beginning on the day after 
the required payment date and ending on 
the date on which payment is made (as de-
termined under subparagraph (C)(iii)). In-
terest amounts paid under this subpara-
graph shall not be counted against the ad-
ministrative costs of an MA plan for pur-
poses of determining the medical loss ratio 
of the plan under subsection (e)(4). 
‘‘(ii) AUTHORITY NOT TO CHARGE IN-
TEREST.—The Secretary may provide that 
an MA organization is not charged interest 
under clause (i) in the case in which there 
are exigent circumstances, including nat-
ural disasters and other unique and unex-
pected events, that prevent the timely proc-
essing of claims. 
‘‘(E) PROTECTING THE RIGHTS OF CLAIM-
ANTS.— 
‘‘(i) IN
GENERAL.—Nothing in this 
paragraph shall be construed to prohibit or 
limit a claim or action not covered by the 
subject matter of this paragraph that any 
individual or organization has against a 
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provider of services, supplier, or an MA or-
ganization. 
‘‘(ii) ANTI-RETALIATION.—Consistent 
with applicable Federal and State laws, an 
MA organization shall not retaliate against 
an individual, provider of services, or sup-
plier for exercising a right of action under 
this subparagraph.’’. 
(2) SECRETARIAL
AUTHORITY
TO
ENFORCE 
PROMPT
PAYMENT
REQUIREMENT.—Section 
1857(g)(1) of the Social Security Act (42 U.S.C. 
1395w–27(g)(1)) is amended— 
(A) in subparagraph (J), by striking at the 
end ‘‘or’’; 
(B) in subparagraph (K), by inserting ‘‘or’’ 
after the semicolon; and 
(C) by inserting after subparagraph (K) 
the following new subparagraph: 
‘‘(L) fails to comply with the provisions of 
subsection (f)(2);’’. 
Æ 
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