Rep. Mark Pocan leads comprehensive legislative package aimed at cracking down on delays, denials, and fraud in Medicare Advantage plans
On November 19, 2025, Representative Mark Pocan (D-Wisconsin) and 12 co-sponsors introduced a comprehensive package of eight bills designed to impose guardrails on Medicare Advantage programs while strengthening traditional Medicare. The legislative package represents one of the most aggressive congressional efforts to date to address mounting concerns about Medicare Advantage plans, which now cover more than half of all Medicare beneficiaries.
The co-sponsors include Andre Carson (D-Indiana), Steve Cohen (D-Tennessee), Rosa DeLauro (D-Connecticut), Lloyd Doggett (D-Texas), Pramila Jayapal (D-Washington), Ro Khanna (D-California), Eleanor Holmes Norton (D-D.C.), Alexandria Ocasio-Cortez (D-New York), Jan Schakowsky (D-Illinois), Mark Takano (D-California), Shri Thanedar (D-Michigan), and Rashida Tlaib (D-Michigan).
The Three-Category Reform Framework
The eight bills fall into three distinct categories addressing the most critical issues plaguing Medicare Advantage: care delays and denials, overcharging taxpayers, and strengthening traditional Medicare.
Category 1: Addressing Delays and Denials of Care
Denials Don’t Pay Act would disincentivize MA plans from delaying and denying care through prior authorization requirements. Prior authorization has become one of the most contentious aspects of Medicare Advantage, with providers and patients frustrated by administrative burden and care delays.
Right to Appeal Patient Insurance Denials (RAPID) Act ensures that patients receive necessary care by automatically appealing any denial. Currently, when Medicare Advantage plans deny care, patients must navigate complex appeals processes—often while facing urgent medical needs. Many beneficiaries lack the knowledge or resources to pursue appeals, resulting in foregone care even when denials are medically unjustified.
Disclose Your Denials Act requires MA plans to audibly and visually disclose their delay and denial rates when advertising. Currently, Medicare Advantage plans saturate media with advertising emphasizing supplemental benefits while remaining silent about denial rates and care restrictions.
Category 2: Preventing Overcharging of Taxpayers
Medicare Advantage Fraud Accountability Act would ban companies from participating in MA if they’ve been convicted of defrauding the government. This addresses a remarkable loophole: companies convicted of defrauding Medicare can continue participating in Medicare Advantage and receiving billions in federal payments.
Keep Medicare Costs Down Act requires MA plans to charge the government per beneficiary as much as or less than traditional Medicare. Currently, the federal government pays Medicare Advantage plans more per beneficiary than it spends on traditional Medicare, despite MA plans often providing more restrictive coverage.
Seniors’ Choice and Clarity Act limits the number of plans that MA companies can provide to just three per year. Currently, some insurance companies offer dozens of different Medicare Advantage plans in a single market, creating confusion that makes meaningful comparison virtually impossible for beneficiaries.
Category 3: Strengthening Traditional Medicare
Protecting Medicare Choice Act prevents Medicare Advantage from being set as the default option for seniors, which was proposed in Project 2025. This proposal alarmed Medicare advocates because it would fundamentally alter Medicare’s structure, shifting the default from a public program to private insurance.
Find My Doctor Act requires CMS to create a national website that allows people to search for doctors by plan. One of the most common problems Medicare Advantage enrollees face is discovering after enrollment that their preferred doctors do not participate in their plan’s network.
The Legislative Rationale
Representative Pocan articulated the urgency behind the legislative package in strong terms: “Only Medicare is Medicare. It is one of the most popular and important services our government provides. But for too long, private healthcare companies taking advantage of Medicare’s brand and popularity have tricked and wronged seniors. This package of commonsense, pro-patient reforms will bring greater accountability, transparency, and affordability to Medicare Advantage, while strengthening traditional Medicare and protecting patient choice.”
Strong Support from Patient Advocacy Organizations
The legislative package has received endorsements from the Center for Health and Democracy, Just Care USA, Labor Campaign for Single Payer, Physicians for a National Health Program, Public Citizen, and Social Security Works.
Diane Archer, president and founder of JustCare, stated: “Medicare Advantage insurers profit from withholding medically necessary care, and can withhold care with near impunity. So, people enrolling in corporate MA plans are forced to gamble with their health and with their lives. They can’t avoid the bad actors. It’s time Congress protected older Americans and people with disabilities from bad actor Medicare Advantage insurers, as Congressman Pocan’s MA Bill package would do.”
Dr. Ed Weisbart of Physicians for a National Health Program offered a pointed assessment: “Medicare Advantage is a tragic emblem of the problems with American health insurance. Profiteers like UnitedHealthcare pervert the system, shorten our lives, and bankrupt our families. This package of bills from Rep. Pocan is a good start at turning things around and giving real Medicare a fighting chance to protect our seniors.”
Understanding the Medicare Advantage Crisis
Medicare Advantage has grown from covering 13% of Medicare beneficiaries in 2004 to more than half—approximately 33 million people—today. This explosive growth has been fueled by aggressive marketing emphasizing supplemental benefits and zero-dollar premiums, made possible by federal payments that exceed traditional Medicare costs.
However, serious structural problems have emerged:
Payment Inflation Through Upcoding: Insurance companies receive higher payments for sicker patients, creating incentives to maximize documented diagnoses even for conditions not being actively treated. Multiple major insurers face allegations of systematically inflating diagnosis codes to receive billions in excess payments.
Care Denials and Delays: MA plans use prior authorization to deny or delay care at rates far exceeding traditional Medicare. When appeals eventually succeed, the delay has already occurred, potentially worsening health outcomes.
Provider Network Restrictions: Unlike traditional Medicare, which allows beneficiaries to see virtually any doctor accepting Medicare, MA plans use narrow networks that limit choice. Plans can change networks mid-year, forcing beneficiaries to find new doctors or pay out-of-network costs.
Administrative Burden: Healthcare providers must navigate different rules, prior authorization requirements, and billing procedures for dozens of different MA plans, creating massive administrative costs.
Implications for Different Stakeholders
For Medicare Beneficiaries: The legislation would provide substantially better protections through automatic appeals, disclosure requirements, and preservation of traditional Medicare as the default option. The Find My Doctor Act would prevent the common scenario where beneficiaries enroll in a plan only to discover their trusted physicians don’t participate.
For Healthcare Providers: The reforms would reduce administrative burden by eliminating improper denials that require extensive appeals. However, the bills don’t directly address reimbursement rate disparities that have driven many providers to abandon Medicare Advantage contracts entirely.
For Insurance Companies: The legislation would substantially constrain current practices. Companies convicted of fraud would be barred from the program. Payment limits would end the practice of receiving more per beneficiary than traditional Medicare costs while providing more restrictive coverage.
For Taxpayers: The reforms would reduce federal spending on Medicare Advantage by eliminating overpayments and barring fraudulent companies from receiving federal funds, potentially saving tens of billions of dollars annually.
Political Challenges to Passage
The package faces significant obstacles. It was introduced exclusively by Democratic representatives with no Republican co-sponsors. In the closely divided House, legislation lacking bipartisan support faces steep hurdles. The insurance industry has enormous financial stakes in Medicare Advantage and dedicates substantial resources to lobbying against reforms that would constrain practices or reduce payments.
What Healthcare Professionals Should Do
1. Stay Informed on Legislative Progress: Track the status of these bills through Congress and engage through professional associations, providing real-world examples of how current MA practices impact patient care.
2. Document Patient Harm: Systematically track cases where Medicare Advantage prior authorization requirements, denials, or delays result in adverse patient outcomes. This documentation provides powerful evidence for legislative advocacy and regulatory action.
3. Educate Patients About Medicare Options: During annual open enrollment periods, provide clear, factual information about network restrictions, prior authorization requirements, and the difference between MA supplemental benefits and Medigap supplemental insurance.
4. Evaluate MA Contract Participation Strategically: Conduct comprehensive financial analysis of actual reimbursement rates, administrative costs, payment delays, and patient access implications of network participation decisions.
5. Engage with CMS on Administrative Reforms: While legislative change faces political obstacles, CMS has substantial authority to modify Medicare Advantage rules through regulation. Provider organizations should engage with CMS rulemaking processes, submitting detailed comments on proposed regulations.
The eight bills introduced by Representative Pocan represent a comprehensive vision for reform—preserving Medicare Advantage as an option while imposing guardrails that prevent harmful practices and protect taxpayers. Whether this approach gains political traction will likely be determined over the next several years as Medicare Advantage’s problems become increasingly difficult to ignore.
For healthcare professionals, the imperative is clear: stay informed, document problems systematically, educate patients, and engage in the policy process to ensure that Medicare—whether traditional or Advantage—actually serves the seniors and people with disabilities it was designed to protect.
Sources
- MedCity News. “Lawmakers Introduce Multiple Bills Aimed at Medicare Advantage Reform.” November 2025. https://medcitynews.com/2025/11/bills-medicare-advantage/
- U.S. House of Representatives. Rep. Mark Pocan Press Release: “Pocan Introduces Package of Bills to Reform Medicare Advantage, Strengthen Traditional Medicare.” November 19, 2025. https://pocan.house.gov/media-center/press-releases/pocan-introduces-package-bills-reform-medicare-…
- Just Care USA. Statement from Diane Archer, President and Founder. November 2025.
- Physicians for a National Health Program. Statement from Dr. Ed Weisbart, Board Member. November 2025.
- Social Security Works. Statement from Alex Lawson, Executive Director. November 2025.
- Labor Campaign for Single Payer. Statement from Rose Roach, National Coordinator. November 2025.
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