This bill would change rules for Medicare Advantage plans that require prior authorization before paying for items or services. Plans that use prior authorization would have to: start a secure electronic prior authorization program by plan years beginning on or after January 1, 2028 (and follow technical standards the Secretary sets); meet enrollee protection standards by that same date; and meet transparency reporting requirements beginning on or after January 1, 2027.
The bill defines what counts as an electronic transmission (excluding fax, proprietary portals that do not meet Secretary standards, or simple electronic forms) and requires these electronic systems to follow technical standards adopted by the Secretary. Plans must report yearly to the Secretary a list of items and services subject to prior authorization and detailed statistics about requests, approvals, denials, appeals, average and median decision times (excluding incomplete requests), use of decision-support or AI technologies, grievances related to prior authorization, and other information the Secretary requires. The Secretary must publish this information on the CMS website at the individual-plan level.
The bill also directs reports: MedPAC must report to Congress on submitted information within 3 years of first submission; the Comptroller General (GAO) must evaluate implementation by January 1, 2032; and CMS and the Office of the National Coordinator must report by January 1, 2028 defining “real-time decision” and analyzing which items could get real-time decisions and how automation affects access and disparities.
Enrollee protection standards include consulting with enrollees and contracted providers when developing prior authorization programs, allowing waiver or modification of prior authorization for providers who meet performance measures, and annual review of items/services requiring prior authorization with input from enrollees and providers. The rules apply to all items and services covered by a Medicare Advantage plan except covered Part D drugs.
The bill also amends the law to give the Secretary authority to set timeframes for Medicare Advantage organizations to respond to prior authorization requests (for example, the Secretary may set timeframes such as 24 hours for expedited requests, real-time decisions, or other requests), and adjusts existing timing language to reference any such Secretary-established timeframes.
If you are enrolled in a Medicare Advantage plan that uses prior authorization, the plan would be required to use a secure electronic prior authorization system and meet new transparency and patient-protection rules. You (or your provider) could request access to the criteria plans use for prior authorization decisions. CMS would publish plan-level data about how plans use prior authorization.
No publicly available information.
The bill creates rules to standardize electronic prior authorization, increase public reporting about prior authorization use (including use of AI), set protections for enrollees, and give the Secretary authority to require timely decisions. Supporters present these requirements as steps to improve timely access to care and oversight of prior authorization in Medicare Advantage.
No publicly available information.