Improving Seniors' Timely Access to Care Act of 2021
This bill establishes several requirements and standards relating to prior authorization processes under Medicare Advantage (MA) plans.
Specifically, 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 117th Congress]
[From the U.S. Government Publishing Office]
[S. 3018 Introduced in Senate (IS)]
<DOC>
117th CONGRESS
1st Session
S. 3018
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 SENATE OF THE UNITED STATES
October 20, 2021
Mr. Marshall (for himself, Ms. Sinema, Mr. Thune, and Mr. Brown)
introduced the following bill; which was read twice and referred to the
Committee on Finance
_______________________________________________________________________
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 2021''.
SEC. 2. 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.--Beginning with the second plan year
beginning after the date of the enactment of this subsection,
in the case of a Medicare Advantage plan that imposes any prior
authorization requirement with respect to any applicable item
or service (other than a covered part D drug) during a plan
year, such plan shall--
``(A) establish the electronic prior authorization
program described in paragraph (2) and issue real-time
decisions with respect to prior authorization requests
for items and services identified by the Secretary
under subparagraph (C)(ii) of such paragraph;
``(B) meet the transparency requirements specified
in paragraph (3); and
``(C) meet the beneficiary protection standards
specified pursuant to paragraph (4).
``(2) Electronic prior authorization program.--
``(A) In general.--For purposes of paragraph
(1)(A), the electronic prior authorization program
described in this paragraph is a program that provides
for the secure electronic transmission of--
``(i) a prior authorization request from a
health care professional to a Medicare
Advantage plan with respect to an applicable
item or service to be furnished to an
individual, including such clinical information
necessary to evidence medical necessity; 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,
Medicare Advantage organizations, and
health information technology software
vendors. In adopting such standards
with respect to which an electronic
transmission described in subparagraph
(A) shall comply, the Secretary shall
ensure that such transmissions support
attachments containing applicable
clinical information and shall
prioritize the adoption of standards
that support integration with
interoperable health information
technology certified under a program of
voluntary certification kept or
recognized by the National Coordinator
for Health Information Technology
consistent with section 3001(c)(5) of
the Public Health Service Act.
``(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 in
accordance with clause (iv)) by a Medicare
Advantage plan with respect to prior
authorization requests for applicable items and
services identified by the Secretary pursuant
to clause (ii) for a plan year if such requests
contain all documentation described in
paragraph (3)(A)(ii)(II) required by such plan.
``(ii) Identification of requests.--For
purposes of clause (i) and with respect to a
period of 2 plan years, the Secretary shall
identify, not later than the date on which the
initial announcement described in section
1853(b)(1)(B)(i) for the first plan year of
such period is required to be announced,
applicable items and services for which prior
authorization requests are routinely approved,
and shall update the identification of such
items and services for each subsequent period
of 2 plan years.
``(iii) Data collection and consultation
with relevant eligible professional
organizations and relevant stakeholders.--The
Secretary shall use the information described
in paragraph (3)(A) (if available) and shall
issue a request for information from Medicare
Advantage plans, providers, suppliers,
beneficiary advocacy organizations, consumer
organizations, and other stakeholders for
purposes of identifying requests for a period
under clause (ii).
``(iv) Definition of real-time decision.--
``(I) In general.--In establishing
the definition of a real-time decision
for purposes of clause (i), the
Secretary shall take into account
current medical practice, technology,
health care industry standards, and
other relevant information and factors
to ensure the accurate and timely
furnishing of items and services to
individuals.
``(II) Update.--The Secretary shall
update, not less often than once every
2 years, the definition of a real-time
decision for purposes of clause (i),
taking into account changes in medical
practice, changes in technology,
changes in health care industry
standards, and other relevant
information, such as the information
submitted by Medicare Advantage plans
under paragraph (3)(A)(i), and factors
to ensure the accurate and timely
furnishing of items and services to
individuals.
``(v) Implementation.--The Secretary shall
use notice and comment rulemaking, which may
include use of the annual call letter process
under this part, for each of the following:
``(I) Establishing the definition
of a `real-time decision' for purposes
of clause (i).
``(II) Updating such definition
pursuant to clause (iv)(II).
``(III) Identifying applicable
items or services pursuant to clause
(ii) for the initial period of 2 plan
years as described in such clause.
``(IV) Updating the identification
of such items and services for each
subsequent period of 2 plan years as
described in such clause.
``(3) Transparency requirements.--
``(A) In general.--For purposes of paragraph
(1)(B), the transparency requirements specified in this
paragraph are, with respect to a Medicare Advantage
plan, the following:
``(i) The plan, annually and in a manner
specified by the Secretary, shall submit to the
Secretary the following information:
``(I) A list of all applicable
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 in
an initial determination with respect
to each such item and service.
``(III) The percentage of such
requests that were initially denied and
that were subsequently appealed in any
manner, and the percentage of such
appealed requests that were overturned,
with respect to each such item and
service, broken down by each stage of
appeal (including judicial review). The
plan may include information regarding
the number of initial denials due to
request submissions that did not meet
clinical evidence standards.
``(IV) The percentage of such
requests that were denied and the
percentage of the total number of
denied requests that were denied as a
result of decision support technology
or other clinical decision-making
tools.
``(V) 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.
``(VI) A list that includes a
description of each occurrence during
the previous plan year in which the
plan made a determination to approve or
deny an item or service in the case
where a provider furnished an
additional or differing item or service
during the peroperative period of a
surgical or otherwise invasive
procedure that such provider determined
was medically necessary.
``(VII) A disclosure and
description of any software decision-
making tools the plan utilizes in
making determinations with respect to
such requests.
``(VIII) Such other information as
the Secretary determines appropriate.
``(ii) The plan shall provide--
``(I) to each provider or supplier
who seeks to enter into a contract with
such plan to furnish applicable items
and services under such 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;
``(II) to each such provider and
supplier who does enter into such a
contract, 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; and
``(III) to each beneficiary subject
to prior authorization under the plan,
access to the criteria used by the plan
for making such determinations, except
to the extent that provision of access
to such criteria would disclose
proprietary information of such plan.
``(B) Regulations.--The Secretary shall, through
notice and comment rulemaking, provide guidance to
Medicare Advantage plans regarding--
``(i) the establishment of criteria
described in subparagraph (A)(ii)(II) and
access to such criteria by providers and
suppliers in accordance with such subparagraph;
and
``(ii) access to such criteria by
beneficiaries in accordance with subparagraph
(A)(ii)(III).
``(C) Medpac report.--Not later than 3 years after
the date information is first submitted under
subparagraph (A)(i), the Medicare Payment Advisory
Commission shall submit to Congress a report on such
information that includes a descriptive analysis of the
use of prior authorization. As appropriate, the
Commission should report on statistics including the
frequency of appeals and overturned decisions. The
Commission shall provide recommendations, as
appropriate, on any improvement that should be made to
the electronic prior authorization programs of Medicare
Advantage plans.
``(4) Beneficiary protection standards.--The Secretary of
Health and Human Services shall, through notice and comment
rulemaking, specify requirements with respect to the use of
prior authorization by Medicare Advantage plans for applicable
items and services to ensure--
``(A) that such plans adopt transparent prior
authorization programs developed in consultation with
providers and suppliers with contracts in effect with
such plans for furnishing such items and services under
such plans that allow for the modification of prior
authorization 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
such items and services for which prior authorization
requirements are imposed under such plans through a
process that takes into account input from providers
and suppliers with such contracts in effect and is
based on analysis of past prior authorization requests
and current coverage and 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 such plans provide information on the
appeals process to the beneficiary when denying any
request for prior authorization with respect to an item
or service.
``(5) Applicable item or service.--For purposes of this
subsection, the term `applicable item or service' means, with
respect to a Medicare Advantage plan, any item or service for
which benefits are available under such plan, other than a
covered part D drug.
``(6) 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 through
the date that is 10 years after such date of enactment, the
Secretary shall submit to Congress a report containing an
evaluation of the implementation of the requirements of this
subsection, an analysis of an issues in implementing such
requirements faced by Medicare Advantage plans, and a
description of the information submitted under paragraph
(3)(A)(i) with respect to--
``(A) in the case of the first such report, such
second plan year; and
``(B) in the case of a subsequent report, the 2
full plan years preceding the date of the submission of
such report.''.
(b) Determination Clarification.--Section 1852(g)(1)(A) of the
Social Security Act (42 U.S.C. 1395w-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 Senate
Read twice and referred to the Committee on Finance.
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