119-hr4559

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4559 Introduced in House

    (IH) ]

<DOC>

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 
 establish 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 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 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 Representatives 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''.

SEC. 2. ESTABLISHING PAYMENT PARITY BETWEEN MEDICARE 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 following 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 provider or supplier, that payment for items 
 and services 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 ESTABLISHING ENFORCEABLE PROMPT PAYMENT REQUIREMENTS 
 AND ENHANCING TRANSPARENCY REGARDING CLAIMS DENIALS.

    (a) Applying Prompt Payment Requirements for Items and Services 
Furnished by In-Network Providers.--

    (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 inserting 
 ``Applicable with respect to out-of-network providers 
 of services and suppliers'' after ``Requirement'';
        (B) in paragraph

    (2) , by striking ``compliance with 
 paragraph

    (1) '' and inserting ``compliance 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 respect 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 organization 
 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 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 
 respect to all clean claims submitted for such 
 items and services furnished by such providers 
 of services and suppliers to such enrollees, 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 accordance 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 
 submitted electronically, on the date 
 on which the claim is transferred; and
 ``
            (II) with respect to claims 
 submitted otherwise, on the 5th day 
 after the postmark date of the claim or 
 the date specified in the time stamp of 
 transmission.
 ``
            (iii) Applicable number of calendar days 
 defined.--For purposes of this paragraph, the 
 term `applicable number of calendar days' 
 means--
 ``
            (I) with respect to claims 
 submitted electronically, 14 days; and
 ``
            (II) with respect to claims 
 submitted otherwise, 30 days.
 ``
        (B) Procedures and rules for determining 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 documentation) 
 or particular circumstance requiring 
 special treatment that prevents timely 
 payment from being made on the claim 
 under this part; and
 ``
            (II) a claim that otherwise 
 conforms to the clean claim 
 requirements for equivalent claims 
 under original Medicare.
 ``
            (ii) Claim deemed to be clean when timely 
 notice of any deficiency 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 services, 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 organization does not provide notice to 
 the provider of services or supplier of any 
 deficiency in the claim--
 ``
            (I) with respect to claims 
 submitted electronically, within 10 
 days after the date on which the claim 
 is received; and
 ``
            (II) with respect to claims 
 submitted otherwise, within 15 days 
 after the date on which the claim is 
 received.
 ``
            (iii) Required notifications and 
 treatment of claims initially determined to not 
 be clean claims.--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 services--
 ``
            (I) if the MA organization 
 determines 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 
 notification shall specify all defects 
 or improprieties in the claim and shall 
 list all additional information or 
 documents necessary for the proper 
 processing and payment of the claim, 
 including detailed instructions for 
 resubmission of claims, how to address 
 each specified defect or impropriety, 
 any formatting or coding guidance 
 specific to the rejection reason, and 
 how to contact the plan to obtain 
 assistance with resubmission; and
 ``
            (II) in the case in which 
 additional information is received 
 pursuant 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 
 received.
 ``
            (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 regarding 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 liability 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 defined in 
 subparagraph
        (A)
            (iii) ) after the date on which 
 the claim is received (as determined 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, remittance may be made 
 by the MA organization electronically as well.
 ``
            (iii) Date of payment of claim.--Payment 
 of a clean claim under this paragraph shall be 
 considered to have been made on the date on 
 which--
 ``
            (I) with respect to claims paid 
 electronically, the payment is 
 transferred; 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 provider 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 for the period beginning on the day after 
 the required payment date and ending on the 
 date on which payment is made (as determined 
 under subparagraph
            (C) 
            (iii) ). Interest amounts 
 paid under this subparagraph shall not be 
 counted against the administrative costs of an 
 MA plan for purposes of determining the medical 
 loss ratio of the plan under subsection

    (e)

    (4) .
 ``
            (ii) Authority not to charge interest.--
 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 natural 
 disasters and other unique and unexpected 
 events, that prevent the timely processing of 
 claims.
 ``
        (E) Protecting the rights of claimants.--
 ``
            (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 
 provider of services, supplier, or an MA 
 organization.
 ``
            (ii) Anti-retaliation.--Consistent with 
 applicable Federal and State laws, an MA 
 organization shall not retaliate against an 
 individual, provider of services, or supplier 
 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) ;''.
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