H.R. 10394 – Protecting Approved Care Act

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Updated September 22, 2026 at 12:41 PM UTC

The Protecting Approved Care Act would change Medicare law to limit how Medicare Advantage (MA) plans can use prior authorization and deny or alter claims. Starting with plan years that begin on or after Jan. 1, 2028, MA contracts must keep coverage and payment decisions for services that were authorized or that did not require authorization, unless there is a clear, regulatory reason such as fraud. The bill applies to people enrolled in MA plans and the MA organizations that run those plans.

Key Provisions

MA plans may not deny coverage or reduce payment for a service after it has been approved through a prior authorization, a concurrent determination, or a transfer authorization.
MA plans may not reopen a coverage or payment decision for a service, except for "good cause" defined in regulations or reliable evidence of fraud.
MA plans may not change the billing code for a service to lower the payment amount, unless the same "good cause" or fraud exceptions apply.
The law defines "specified authorization" to include prior authorizations, concurrent determinations, and authorizations for hospital or post‑acute care transfers.

Legislative Activity

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HouseIntro Referral Latest Action

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.

Ways and Means Committee

September 15, 2026

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HouseIntro Referral

Introduced in House

September 15, 2026

HouseIntro Referral

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.

Ways and Means Committee

September 15, 2026

Bill Text

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Introduced in HouseIssued September 15, 2026

I

119th CONGRESS

2d Session

H. R. 10394

IN THE HOUSE OF REPRESENTATIVES

September 15, 2026

Mr. Landsman (for himself and Mr. Onder) 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 requirements with respect to the use of prior authorization and claims denial under Medicare Advantage plans.

1.

Short title

This Act may be cited as the Protecting Approved Care Act.

2.

Establishing requirements with respect to the use of prior authorization and claims denial under Medicare Advantage plan

Section 1857(e) of the Social Security Act (42 U.S.C. 1395e–27(e)) is amended by adding at the end the following new paragraph:

(7)

Limitations on claims denial for covered items and services

(A)

In general

Beginning with plan years beginning on or after January 1, 2028, a contract under this section with an MA organization shall require that—

(i)

in the case that the MA organization approves the furnishing to an individual enrolled under an MA plan offered by such MA organization of an item or service through a specified authorization made during the receipt by the individual of such item or service, the MA organization may not, after such approval, take any of the actions described in subparagraph (B) with respect to such item or service; and

(ii)

in the case that there is no requirement to obtain a specified authorization with respect to an item or service for which benefits are available under the plan, the MA organization may not, after an individual enrolled under such plan receives such item or service, take any of the actions described in subparagraph (B) with respect to such item or service.

(B)

Actions described

For purposes of subparagraph (A), the actions described in this subparagraph are, with respect to an MA organization and an item or service, the following:

(i)

Denying coverage of such item or service on the basis of lack of medical necessity.

(ii)

Reopening a determination of coverage or payment made with respect to such item or service (including a specified authorization) for any reason other than—

(I)

good cause (as described in sections 405.986 and 422.616 of title 42, Code of Federal Regulations (or any successor regulation)); or

(II)

reliable evidence of fraud or similar fault (as such terms are defined in section 405.902 of such title (or any successor regulation)), as determined in accordance with section 422.616 of such title (or any successor regulation).

(iii)

Changing the code assigned with respect to the claim for such item or service such that the amount of payment for such claim would be reduced, except for good cause (as described in clause (ii)) or if there is reliable evidence of fraud or similar fault (as so described).

(C)

Specified authorization defined

In this paragraph, the term specified authorization—

(i)

means, with respect to an individual enrolled under an MA plan offered by a Medicare Advantage organization, an authorization of coverage or payment for an item or service through—

(I)

a prior authorization or preservice determination of coverage or payment; or

(II)

a concurrent determination made while the individual is receiving the relevant item or service; and

(ii)

includes an authorization for a transfer of the individual between hospitals or between a hospital and post-acute care facility.

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