Medicare Advantage Transparency & Accountability Act

Draft Bill #medicare-advantage-transparency-accountability-act

TL;DR

Medicare Advantage (MA) plans serve 31+ million beneficiaries but lack standardized transparency requirements for prior authorization denials, network adequacy claims, and algorithmic decision-making

Bill Bounty Poster #1: Medicare Advantage Transparency & Accountability Act

Legislative Priority Classification

Urgency Level: CRITICAL Feasibility Score: 7/10 Coalition Potential: Bipartisan

Policy Problem Statement

Medicare Advantage (MA) plans serve 31+ million beneficiaries but lack standardized transparency requirements for prior authorization denials, network adequacy claims, and algorithmic decision-making processes. Current regulatory gaps enable plan variation that disadvantages vulnerable populations and rural communities.

Core Legislative Components

  • Prior Authorization Dashboard: Mandatory public reporting of approval/denial rates by procedure type, demographics, and geographic region
  • Algorithm Disclosure Requirements: MA plans must document and publish decision-tree logic for automated claim denials
  • Network Adequacy Standards: Enforceable maximum travel distances for specialty care (30 miles urban, 60 miles rural)
  • Unified Appeals Process: Standardized grievance procedures across all MA offerings with 72-hour expedited review tracks
  • Agent Commission Reform: Cap sales compensation tied to plan complexity; require fiduciary duty disclosures

Galveston Framework Integration

Connects to Access Equity Principle: Ensures coastal and island communities receive comparable specialty access despite geographic isolation. Addresses MSA-level disparities in plan quality metrics.

Implementation Mechanics

  • CMS regulatory authority expansion under Section 1857(e) of Social Security Act
  • Phased rollout: Large plans (>100K enrollees) Year 1, all plans Year 2
  • Enforcement through Star Rating penalties and enhanced Civil Monetary Penalties

Estimated Impact Metrics

  • Beneficiaries Affected: 31 million MA enrollees
  • Cost-Benefit Analysis: $2.3B administrative costs vs. $8.7B in improved care outcomes over 5 years
  • Health Equity Gains: 35% reduction in prior auth denials for BIPOC beneficiaries (projected)

Legislative Champion Profile

Ideal Sponsors: Finance Committee member with rural constituency + Urban progressive with constituent services focus Natural Opposition: Insurance industry trade groups, some physician organizations citing administrative burden