Improving Seniors' Timely Access to Care Act of 2019
This bill establishes several prohibitions, requirements, and standards relating to prior authorization processes under Medicare Advantage (MA) plans.
Specifically, the bill prohibits MA plans from instituting additional prior authorization requirements for surgeries (including related items) that are furnished to a patient during other surgeries for which prior authorization was not required or was already received.
Additionally, MA plans must (1) establish an electronic prior authorization program that meets specified standards, including the ability to provide real-time decisions in response to requests for items and services that are routinely approved; (2) annually publish specified prior authorization information, including the percentage of requests approved and the average response time; and (3) meet other standards, as set by the Centers for Medicare & Medicaid Services, relating to the quality and timeliness of prior authorization determinations.
[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3107 Introduced in House (IH)]
<DOC>
116th CONGRESS
1st Session
H. R. 3107
To amend title XVIII of the Social Security Act to establish
requirements with respect to the use of prior authorization under
Medicare Advantage plans, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 5, 2019
Ms. DelBene (for herself, Mr. Kelly of Pennsylvania, Mr. Marshall, and
Mr. Bera) 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 under
Medicare Advantage plans, and for other purposes.
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 ``Improving Seniors' Timely Access to
Care Act of 2019''.
SEC. 2. SENSE OF CONGRESS.
It is the sense of Congress that--
(1) use of prior authorization should be streamlined
through electronic transmissions for coverage of covered
services for individuals enrolled in federally funded programs
such as Medicare, Medicaid, and federally contracted managed
care plans to improve patient access to medically appropriate
services and reduce administrative burden through automation
informed by clinical decision support;
(2) there should be increased transparency for
beneficiaries and providers and increased oversight by the
Centers for Medicare & Medicaid Services on the processes used
for prior authorization; and
(3) prior authorization is a tool that can be used to
responsibly prevent unnecessary care and promote safe and
evidence-based care.
SEC. 3. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR
AUTHORIZATION UNDER MEDICARE ADVANTAGE PLANS.
(a) In General.--Section 1852 of the Social Security Act (42 U.S.C.
1395w-22) is amended by adding at the end the following new subsection:
``(o) Prior Authorization Requirements.--
``(1) In general.--In the case of a Medicare Advantage plan
that imposes any prior authorization requirement with respect
to any benefit, such plan shall, beginning with the first plan
year beginning on or after the date of the enactment of this
subsection--
``(A) comply with the prohibition described in
paragraph (2);
``(B) establish the electronic prior authorization
program described in paragraph (3);
``(C) meet the transparency requirements specified
in paragraph (4); and
``(D) meet the beneficiary protection standards
specified pursuant to paragraph (5).
``(2) Prohibition on prior authorization with respect to
certain items and services.--A Medicare Advantage plan may not
impose any additional prior authorization requirement with
respect to any surgical procedure or otherwise invasive
procedure (as defined by the Secretary), and any item furnished
as part of such surgical or invasive procedure, if such
procedure (or item) is furnished during the peroperative period
of a procedure for which--
``(A) prior authorization was received from such
plan before such surgical or otherwise invasive
procedure (or item furnished as part of such surgical
or otherwise invasive procedure) was furnished; or
``(B) prior authorization was not required by such
plan.
``(3) Electronic prior authorization program.--
``(A) In general.--For purposes of paragraph
(1)(B), the electronic prior authorization program
described in this paragraph is a prior authorization
process implemented by a Medicare Advantage plan that
provides for the secure electronic transmission of--
``(i) a prior authorization request from a
health care professional to such plan with
respect to an item or service to be furnished
to an individual, including such clinical
information as the professional determines
appropriate to support the furnishing of such
item or service to such individual; and
``(ii) a response, in accordance with this
paragraph, from such plan to such professional.
``(B) Electronic transmission.--
``(i) Exclusions.--For purposes of this
paragraph, a facsimile, a proprietary payer
portal that does not meet standards specified
by the Secretary, or an electronic form shall
not be treated as an electronic transmission
described in subparagraph (A).
``(ii) Standards.--
``(I) In general.--In order to
ensure appropriate clinical outcome for
individuals, for purposes of this
paragraph, an electronic transmission
described in subparagraph (A) shall
comply with technical standards adopted
by the Secretary in consultation with
standard-setting organizations
determined appropriate by the
Secretary, health care professionals,
MA organizations, and health
information technology software
vendors. In adopting such standards,
the Secretary shall ensure that such
transmissions support attachments
containing applicable clinical
information and shall prioritize the
adoption of standards that encourage
integration of the electronic prior
authorization program into established
electronic health record systems.
``(II) Transaction standard.--The
Secretary shall include in the
standards adopted under subclause (I) a
standard with respect to the
transmission of attachments described
in such subclause, and data elements
and operating rules for such
transmission, consistent with health
care industry standards.
``(C) Real-time decisions.--
``(i) In general.--The program described in
subparagraph (A) shall provide for real-time
decisions (as defined by the Secretary) with
respect to requests identified by the Secretary
pursuant to clause (ii) for a plan year if such
requests contain all information required by an
MA plan to evaluate the criteria described in
paragraph (4)(A)(iii)(II).
``(ii) Identification of requests.--For
purposes of clause (i) and with respect to a
plan year, the Secretary shall identify, not
later than the date on which the initial
announcement described in section
1853(b)(1)(B)(i) for such plan year is required
to be announced, items and services for which
prior authorization requests are routinely
approved.
``(iii) Data collection and consultation
with relevant eligible professional
organizations and relevant stakeholders.--In
identifying requests for a year under clause
(ii), the Secretary shall use the information
described in paragraph (4)(A) (if available)
and shall issue a request for information from
providers, suppliers, patient advocacy
organizations, and other stakeholders.
``(4) Transparency requirements.--
``(A) In general.--For purposes of paragraph
(1)(C), the transparency requirements specified in this
paragraph are, with respect to a Medicare Advantage
plan, the following:
``(i) The plan, not less frequently than
annually and at a time and in a manner
specified by the Secretary, shall submit to the
Secretary the following information:
``(I) A list of all items and
services that are described in
subsection (a)(1)(B) that are subject
to a prior authorization requirement
under the plan.
``(II) The percentage of prior
authorization requests approved during
the previous plan year by the plan with
respect to each such item and service.
``(III) The percentage of such
requests that were initially denied and
that were subsequently appealed, and
the percentage of such appealed
requests that were overturned, with
respect to each such item and service.
``(IV) The average and the median
amount of time (in hours) that elapsed
during the previous plan year between
the submission of such a request to the
plan and a determination by the plan
with respect to such request for each
such item and service, excluding any
such requests that did not contain all
information required to be submitted by
the plan.
``(V) Such other information as the
Secretary determines appropriate after
consultation with and comment from
stakeholders.
``(ii) The plan shall publish the
information described in clause (i) annually
before open enrollment on a publicly available
website. Such plan shall provide the address of
such website in any enrollment materials
distributed by the plan and shall update such
website in a timely manner.
``(iii) The plan shall provide--
``(I) along with contract materials
for any provider or supplier who seeks
to participate under the plan, the list
described in clause (i)(I) and any
policies or procedures used by the plan
for making determinations with respect
to prior authorization requests; and
``(II) to each provider and
supplier participating under the plan,
access to the criteria used by the plan
for making such determinations,
including an itemization of the medical
or other documentation required to be
submitted by a provider or supplier
with respect to such a request, except
to the extent that provision of access
to such criteria would disclose
proprietary information of such plan,
as determined by the Secretary.
``(B) Report to congress.--Not later than the end
of the second plan year beginning on or after the date
of the enactment of this subsection, and biennially
thereafter, the Secretary shall submit to Congress a
report describing the information submitted under
subparagraph (A)(i) with respect to--
``(i) in the case of the first such report,
the first plan year beginning on or after such
date; and
``(ii) in the case of a subsequent report,
the 2 full plan years preceding the date of the
submission of such report.
``(5) Beneficiary protection standards.--The Secretary of
Health and Human Services shall, through notice and comment
rulemaking, specify standards with respect to the use of prior
authorization by MA plans to ensure--
``(A) that such plans adopt transparent programs
developed in consultation with providers and suppliers
participating under the plans that promote the
modification of such requirements based on the
performance of such providers and suppliers with
respect to adherence to evidence-based medical
guidelines and other quality criteria;
``(B) that such plans conduct annual reviews of
items and services for which prior authorization
requirements are imposed under such plans through a
process that takes into account input from
participating providers and suppliers and is based on
analysis of past prior authorization requests and
current clinical criteria;
``(C) continuity of care for individuals
transitioning to, or between, coverage under such plans
in order to minimize any disruption to ongoing
treatment attributable to prior authorization
requirements under such plans;
``(D) that such plans make timely prior
authorization determinations, provide rationales for
denials, and ensure requests are reviewed by qualified
medical personnel; and
``(E) that plans assist providers and suppliers in
submitting the information necessary to enable the plan
to make a prior authorization determination in a timely
manner.''.
(b) Determination Clarification.--Section 1852(g)(1)(A) of the
Social Security Act (42 U.S.C. 1392w-22(g)(1)(A)) is amended by
inserting ``(including any decision made with respect to a prior
authorization request for such service)'' after ``section''.
<all>
Introduced in House
Introduced in House
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.
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.
Referred to the Subcommittee on Health.
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