Summary#
The Prior Authorization Accountability Act would amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), the Internal Revenue Code, and the Affordable Care Act. It would require covered health plans and insurers that use prior authorization to report and publish information about requests, denials, appeals, decision times and technology; its stated goal is greater transparency. The bill is in progress and is not law.
- For plan years beginning on or after January 1, 2027, covered plans and insurers would have to submit the information to the Secretary and post it on a public website.
- Reports would list services subject to prior authorization and give approval and denial counts and rates, including totals and breakdowns by service.
- Reports would show how often denied requests were appealed, how often resolved appeals led to approval, and appeal results by service and appeal level, including judicial review.
- Reports would include average and median decision times by service. Requests missing required medical or other documents would be left out of those time calculations.
- Plans and insurers would report approvals and denials made solely using specified decision technologies, and describe the technologies used.
- For Exchange plan enrollments beginning in 2029, an Exchange website would include the latest submitted information for a qualifying plan that was also offered through that Exchange in a previous plan year.
What it means for you#
- People with health coverage: You could see public information about prior authorization in plans that use it. The bill does not directly change what care is covered, the standards for approving care, or whether plans may require prior authorization.
- People comparing Exchange plans: Starting with 2029 enrollments, Exchange comparison information would include the latest report for a plan offered there in a previous plan year. The bill does not say this display applies to a plan with no previous Exchange offering.
- Health plans and insurers: They would have to collect, submit and publicly post the required information for each plan or coverage. The Secretary would set when and how they submit it. The bill does not set application, review or appeal procedures for patients.
- Exchanges: Their websites would have to include the specified prior authorization information in comparative plan details for eligible plans and enrollments.
Money#
No cost information is in the available material.
- Plans and insurers would have to report and publish data; the bill gives no estimate of their staffing, technology or other costs.
- The Secretary and Exchanges would have implementation and display responsibilities, but no public cost estimate is provided.
- The bill does not set a fee, fine, benefit payment or tax change.
What is unclear#
- The bill does not set the reporting deadline or detailed reporting format; it leaves the time and manner to the Secretary.
- It does not explain how reports will be checked for accuracy or what happens if a plan or insurer does not comply.
- It does not define key terms such as “prior authorization” or specify how to count requests, denials, appeals or technology-assisted decisions.
- It does not explain how information from different plans will be made comparable, or how the Secretary would decide whether to require aggregate reporting.
- The parent Acts were not supplied, so existing reporting duties, enforcement rules and how these new requirements would interact with current law could not be verified.
Case for#
- A possible argument for the bill is that people could compare plans using more than a plan’s stated coverage: they could see denial rates, appeal outcomes and decision times.
- Reporting by service could show where approval patterns differ, while appeal results could show how often an initial denial is later reversed.
- Disclosure of technology use could give the public information about whether and how automated tools were involved in decisions.
- Posting data publicly and adding it to Exchange comparisons could make the information easier to find when choosing coverage.
Case against#
- The bill requires many figures but does not explain how to make them comparable. Differences in counting or reporting could make comparisons misleading.
- Denial rates and appeal outcomes do not explain why a request was denied or whether the decision was appropriate.
- Excluding requests without required documents from decision-time calculations could leave out delays that matter to patients.
- The bill does not provide cost estimates or spell out accuracy checks and consequences for failing to report.