I 
119TH CONGRESS 
1ST SESSION H. R. 6109 
To amend title XVIII of the Social Security Act to establish certain require-
ments with respect to rates of reversed prior authorization coverage 
determinations under Medicare Advantage plans. 
IN THE HOUSE OF REPRESENTATIVES 
NOVEMBER 18, 2025 
Mr. POCAN (for himself, Mr. CARSON, Mr. COHEN, Ms. DELAURO, Mr. DOG-
GETT, Ms. JAYAPAL, Mr. KHANNA, Ms. NORTON, Ms. OCASIO-CORTEZ, 
Ms. SCHAKOWSKY, Mr. TAKANO, Mr. THANEDAR, Ms. TLAIB, Ms. JOHN-
SON 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 con-
cerned 
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 Medi-
care Advantage plans. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. ESTABLISHING REQUIREMENTS WITH RESPECT 
TO RATES OF REVERSED PRIOR AUTHORIZA-
TION 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
DETERMINA-
TIONS.— 
‘‘(A) IN GENERAL.—In the case of a Medi-
care Advantage plan that imposes any prior au-
thorization 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 Sec-
retary shall terminate the contract with respect 
to the offering of such plan under this section. 
‘‘(B) ALLOWABLE
RATE
OF
REVERSED 
PRIOR AUTHORIZATION COVERAGE DETERMINA-
TIONS.—For purposes of subparagraph (A), a 
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described in subclause (I) occurred be-
cause the Medicare Advantage organi-
zation that offers such plan failed to 
appropriately reconsider prior author-
ization 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 deter-
mination’ means, with respect to a Medicare 
Advantage plan, a coverage determination made 
under section 1852(g) regarding whether an in-
dividual enrolled in such plan is entitled to re-
ceive an item or service under the prior author-
ization 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 fail-
ure to meet the requirement under subsection 
(e)(6),’’ before ‘‘the Secretary’’. 
Æ 
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