119-hr3514

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3514 Introduced in House

    (IH) ]

<DOC>

119th CONGRESS
 1st Session
 H. R. 3514

 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 HOUSE OF REPRESENTATIVES

 May 20, 2025

 Mr. Kelly of Pennsylvania (for himself, Ms. DelBene, Mr. Joyce of 
 Pennsylvania, Mr. Bera, Ms. Van Duyne, Ms. Chu, Mr. Crenshaw, Ms. 
Clarke of New York, Mr. Murphy, Ms. Moore of Wisconsin, Mr. Balderson, 
 Ms. Schrier, Mr. Yakym, Ms. Sewell, Mrs. Harshbarger, Mr. Larson of 
Connecticut, Mr. Carey, Mr. Evans of Pennsylvania, Ms. Malliotakis, Mr. 
 Beyer, Ms. Tenney, Ms. Tokuda, Mrs. Miller of West Virginia, Ms. 
 Stevens, Mr. Fitzpatrick, Mr. Costa, Mr. Smucker, Ms. Pressley, Mr. 
 LaHood, Mr. Davis of North Carolina, Mr. Meuser, Mr. Pocan, Ms. 
Salazar, Mr. Fields, Mr. Bacon, Mr. Foster, Mr. Mann, Ms. Brownley, Mr. 
 Ciscomani, Mr. Conaway, Mr. Finstad, Ms. Bonamici, Mr. Shreve, Ms. 
 Norton, Mrs. Kiggans of Virginia, Mr. Deluzio, Mr. Thompson of 
Pennsylvania, Mr. Mrvan, Mr. Moulton, Mr. Case, Ms. McBride, Ms. Ross, 
 Ms. Budzinski, Mr. Quigley, Mr. Sorensen, Mr. McGarvey, Ms. Davids of 
 Kansas, Ms. Brown, Mr. Crow, Mr. Torres of New York, Ms. Wasserman 
Schultz, Mr. Stanton, Mr. Levin, Mr. Keating, Ms. Johnson of Texas, Mr. 
 Vicente Gonzalez of Texas, Ms. Goodlander, Ms. Craig, Mr. Goldman of 
 New York, Ms. Barragan, Ms. Balint, Mr. Ryan, Ms. Houlahan, and Mrs. 
Miller-Meeks) 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.

 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.''.
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