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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 1816 Introduced in Senate (IS)]
<DOC>
119th CONGRESS
1st Session
S. 1816
To amend title XVIII of the Social Security Act to establish
requirements with respect to the use of prior authorization under
Medicare Advantage plans.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
May 20, 2025
Mr. Marshall (for himself, Mr. Warner, Ms. Hassan, Mr. Fetterman, Ms.
Klobuchar, Mr. Cassidy, Mrs. Capito, Mr. Hickenlooper, Mr. Lankford,
Mr. Merkley, Mrs. Blackburn, Ms. Lummis, Mrs. Hyde-Smith, Mr. Kaine,
Mrs. Shaheen, Mr. Rounds, Mr. Padilla, Mr. Hagerty, Mr. Kim, Mr.
Boozman, Mr. Durbin, Mr. Cornyn, Mrs. Murray, Mr. Moran, Mrs.
Gillibrand, Ms. Cantwell, Ms. Hirono, Mr. Tillis, Mr. Booker, Ms.
Smith, Mr. Welch, Mr. Whitehouse, Mr. Budd, Ms. Cortez Masto, Mr.
Sheehy, Ms. Baldwin, Mr. Ricketts, Mr. Blumenthal, Ms. Warren, Ms.
Duckworth, Mr. Hoeven, Mr. Scott of Florida, Mr. Kelly, Ms. Rosen, Mr.
Heinrich, Mrs. Fischer, Mr. Coons, and Mr. Hawley) 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.
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 2025''.
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.--In the case of a Medicare Advantage plan
that imposes any prior authorization requirement with respect
to any applicable item or service (as defined in paragraph (5))
during a plan year, such plan shall--
``(A) beginning with plan years beginning on or
after January 1, 2028--
``(i) establish the electronic prior
authorization program described in paragraph
(2); and
``(ii) meet the enrollee protection
standards specified pursuant to paragraph (4);
and
``(B) beginning with plan years beginning on or
after January 1, 2027, meet the transparency
requirements specified in paragraph (3).
``(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
provider or supplier to a Medicare Advantage
plan with respect to an applicable item or
service to be furnished to an individual and a
response, in accordance with this paragraph,
from such plan to such provider or supplier;
and
``(ii) any supporting documentation
relating to such request or response.
``(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.--An electronic
transmission described in subparagraph (A)
shall comply with applicable technical
standards and other requirements to promote the
standardization and streamlining of electronic
transactions adopted by the Secretary.
``(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 were subject to
a prior authorization requirement under
the plan during the previous plan year.
``(II) The percentage and number of
specified requests (as defined in
subparagraph (F)) approved during the
previous plan year by the plan in an
initial determination and the
percentage and number of specified
requests denied during such plan year
by such plan in an initial
determination (both in the aggregate
and categorized by each item and
service).
``(III) The percentage and number
of specified requests that were denied
during the previous plan year by the
plan in an initial determination and
that were subsequently appealed.
``(IV) The number of appeals of
specified requests resolved during the
preceding plan year, and the percentage
and number of such resolved appeals
that resulted in approval of the
furnishing of the item or service that
was the subject of such request,
categorized by each applicable item and
service and categorized by each level
of appeal (including judicial review).
``(V) The percentage and number of
specified requests that were denied,
and the percentage and number of
specified requests that were approved,
by the plan during the previous plan
year through the utilization of
decision support technology, artificial
intelligence technology, machine-
learning technology, clinical decision-
making technology, or any other
technology specified by the Secretary.
``(VI) The average and the median
amount of time (in hours) that elapsed
during the previous plan year between
the submission of a specified 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 were not
submitted with the medical or other
documentation required to be submitted
by the plan.
``(VII) The percentage and number
of specified requests that were
excluded from the calculation described
in subclause (VI) based on the plan's
determination that such requests were
not submitted with the medical or other
documentation required to be submitted
by the plan.
``(VIII) Information on each
occurrence during the previous plan
year in which, during a surgical or
medical procedure involving the
furnishing of an applicable item or
service with respect to which such plan
had approved a prior authorization
request, the provider or supplier
furnishing such item or service
determined that a different or
additional item or service was
medically necessary, including a
specification of whether such plan
subsequently approved the furnishing of
such different or additional item or
service.
``(IX) A disclosure and description
of any technology described in
subclause (V) that the plan utilized
during the previous plan year in making
determinations with respect to
specified requests.
``(X) The number of grievances (as
described in subsection (f)) received
by such plan during the previous plan
year that were related to a prior
authorization requirement.
``(XI) 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 that enters into such a
contract, access to the criteria used
by the plan for making such
determinations and an itemization of
the medical or other documentation
required to be submitted by a provider
or supplier with respect to such a
request; and
``(III) to an enrollee of the plan,
upon request, access to the criteria
used by the plan for making
determinations with respect to prior
authorization requests for an item or
service.
``(B) Option for plan to provide certain additional
information.--As part of the information described in
subparagraph (A)(i) provided to the Secretary during a
plan year, a Medicare Advantage plan may elect to
include information regarding the percentage and number
of specified requests made with respect to an
individual and an item or service that were denied by
the plan during the preceding plan year in an initial
determination based on such requests failing to
demonstrate that such individuals met the clinical
criteria established by such plan to receive such items
or services.
``(C) Regulations.--The Secretary shall, through
notice and comment rulemaking, establish requirements
for Medicare Advantage plans regarding the provision
of--
``(i) access to criteria described in
subparagraph (A)(ii)(II) to providers of
services and suppliers in accordance with such
subparagraph; and
``(ii) access to such criteria to enrollees
in accordance with subparagraph (A)(ii)(III).
``(D) Publication of information.--The Secretary
shall publish information described in subparagraph
(A)(i) and subparagraph (B) on a public website of the
Centers for Medicare & Medicaid Services. Such
information shall be so published on an individual plan
level and may in addition be aggregated in such manner
as determined appropriate by the Secretary.
``(E) 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.
``(F) Specified request defined.--For purposes of
this paragraph, the term `specified request' means a
prior authorization request made with respect to an
applicable item or service.
``(4) Enrollee protection standards.--For purposes of
paragraph (1)(A)(ii), with respect to the use of prior
authorization by Medicare Advantage plans for applicable items
and services, the enrollee protection standards specified in
this paragraph are--
``(A) the adoption of transparent prior
authorization programs developed in consultation with
enrollees and with providers and suppliers with
contracts in effect with such plans for furnishing such
items and services under such plans;
``(B) allowing for the waiver or modification of
prior authorization requirements based on the
performance of such providers and suppliers in
demonstrating compliance with such requirements, such
as adherence to evidence-based medical guidelines and
other quality criteria; and
``(C) conducting 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 enrollees and from providers
and suppliers with such contracts in effect and is
based on consideration of prior authorization data from
previous plan years and analyses of current coverage
criteria.
``(5) Applicable item or service defined.--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) Reports to congress.--
``(A) GAO.--Not later than January 1, 2032, the
Comptroller General of the United States shall submit
to Congress a report containing an evaluation of the
implementation of the requirements of this subsection
and an analysis of issues in implementing such
requirements faced by Medicare Advantage plans.
``(B) HHS.--
``(i) The secretary.--Not later than the
end of the fifth plan year beginning 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 a description of the information
submitted under paragraph (3)(A)(i) during--
``(I) in the case of the first such
report, the fourth plan year beginning
after the date of the enactment of this
subsection; and
``(II) in the case of a subsequent
report, the 2 plan years preceding the
year of the submission of such report.
``(ii) CMS.--Not later than January 1,
2028, the Centers for Medicare & Medicaid
Services and the Office of National Coordinator
for Health Information Technology shall submit
to Congress and publish on the internet website
of the Centers for Medicare & Medicaid Services
a report that--
``(I) defines the term `real-time
decision' and details how the
definition for such term may be updated
based on any technological advances;
``(II) using the data submitted to
the Secretary under paragraph
(3)(A)(i), details a process for real-
time decisions for routinely approved
items and services for purposes of the
electronic prior authorization program
described in paragraph (2); and
``(III) includes an analysis of--
``(aa) items and services
that are routinely approved;
``(bb) items and services
identified in item (aa) that
could be eligible for real-time
decisions;
``(cc) whether establishing
real-time decisions for such
items and services could--
``(AA) improve
enrollee access to
benefits under this
part;
``(BB) produce
operational
efficiencies for
providers and suppliers
and Medicare Advantage
plans; and
``(CC) reduce
health disparities for
Medicare Advantage
enrollees in rural and
low-income communities;
and
``(dd) how determinations
of routinely approved items and
services made solely through
automation and artificial
intelligence by Medicare
Advantage plans impact patient
access, including disparities
in access for rural and low-
income beneficiaries.''.
(b) Providing the Secretary Authority To Enforce Timely Responses
for All Prior Authorization Requests Submitted Under Part C.--Section
1852(g) of the Social Security Act (42 U.S.C. 1395w-22(g)) is amended--
(1) in paragraph (1)(A), by inserting ``and in accordance
with any timeframe established by the Secretary under paragraph
(6)'' after ``paragraph (3)'';
(2) in paragraph (3)(B)(iii), by inserting ``(with respect
to prior authorization requests submitted on or after the first
day of the third plan year beginning after the date of the
enactment of the Improving Seniors' Timely Access to Care Act
of 2025, any timeframe established by the Secretary under
paragraph (6))'' after ``72 hours''; and
(3) by adding at the end the following new paragraph:
``(6) Timeframe for response to prior authorization
requests.--Subject to paragraph (3), the Secretary may
establish, for purposes of an organization determination made
with respect to a prior authorization request for an item or
service to be furnished to an individual, timeframes, such as
24 hours, for the organization to notify the enrollee (and the
physician involved, as appropriate) of such determination for--
``(A) a request for expedited determination
described in paragraph (3)(A);
``(B) a real time decision for routinely approved
items and services; and
``(C) any other prior authorization request.''.
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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