This bill would change how prior authorization works for Medicare. For Medicare Advantage plans, it would bar plans from requiring prior authorization for most items and services starting with plan years that begin on or after January 1, 2027. Two categories are excluded from that ban: drugs covered under Medicare Part D and supplemental benefits that plans offer. The bill adds a rule that allows the agency to impose intermediate sanctions on plans that keep using prior authorization in violation of the new ban. It also updates an existing rule about prior authorization reviews for plan years ending before January 1, 2027.
The bill also stops the Department of Health and Human Services from implementing the WISeR model (a CMMI model described in a 2025 notice) and prevents the agency from choosing future CMMI models that would test prior authorization in traditional Medicare. For models tested under traditional Medicare, the bill bars models that would use prior authorization for Part A or Part B items or services. It also prohibits models that would issue coverage or payment denials based solely on automated decision processes (like artificial intelligence or algorithms) unless a physician has individually reviewed and approved the denial using independent medical judgment and relevant documentation. The bill further requires that only Medicare administrative contractors process prior authorization requests in such models. Finally, for models selected on or after January 1, 2027, the bill requires notice and an opportunity for public comment before selection.
No publicly available information.
No publicly available information in the bill text about proponents' arguments. Sponsors listed in the bill metadata include Ro Khanna, Pramila Jayapal, Steve Cohen, Debbie Dingell, Jonathan Jackson, Eleanor Norton, and Mark Pocan.
No publicly available information in the bill text about opponents' arguments.