Improving Seniors’ Timely Access Act

Summary#

This bill would change Medicare law (Title XVIII of the Social Security Act) to set rules for how Medicare Advantage plans use prior authorization. If a plan requires prior authorization for any service, the plan must meet new transparency and consumer-protection rules and must create an electronic prior authorization program. The bill sets start dates: transparency reporting begins for plan years starting on or after January 1, 2027, and electronic prior authorization must be in place for plan years beginning on or after January 1, 2028. The bill excludes covered Part D drugs from these rules.

The bill requires plans to send secure electronic prior authorization requests and responses, and says fax, certain proprietary portals, or electronic forms do not count as the required electronic transmission unless they meet standards the Secretary sets. Plans must follow technical standards set by the Secretary for electronic transmission.

Plans must annually submit detailed information to the Secretary about which items and services required prior authorization and statistics about approvals, denials, appeals, use of decision technologies (like AI), average and median response times (in hours), and grievances related to prior authorization. The Secretary must publish this information on the CMS website at the plan level. MedPAC must report to Congress about prior authorization use within three years after the first submissions. The GAO and HHS (including CMS and ONC) must also provide reports on implementation and on defining and supporting "real-time decisions."

The bill adds enrollee protection standards. Plans must develop transparent prior authorization programs with input from enrollees and network providers, allow waiver or modification of prior authorization for providers who meet performance criteria, and review prior authorization lists and policies at least annually with stakeholder input.

The Secretary is given authority to set timeframes (for example, 24 hours) for plans to notify enrollees and involved physicians of determinations on prior authorization requests, including expedited requests and real-time decisions. The Secretary may enforce these timeframes.

What it means for you#

• If you are enrolled in a Medicare Advantage plan that uses prior authorization, that plan must meet new transparency and protection rules and set up an electronic prior authorization system by the dates in the bill.
• Providers and suppliers must be able to send prior authorization requests securely and get timely electronic responses under standards set by the Secretary.
• Plans must give prospective and contracted providers access to the list of services that require prior authorization, the criteria used for decisions, and the documentation required. Enrollees can request access to criteria for a given item or service.
• CMS will publish plan-level prior authorization data, which may make it easier to see how often a plan approves or denies requests and how quickly it responds.
• The Secretary can set and enforce time limits for plan responses, which could speed some decisions, including expedited or real-time decisions.

Expenses#

No publicly available information.

Proponents' View#

The bill’s text aims to improve seniors' timely access to care by standardizing and modernizing prior authorization under Medicare Advantage. It seeks to increase transparency about which services require prior authorization and how plans make decisions, require secure electronic exchanges to speed decisions, add enrollee protections and review processes, and give the Secretary authority to set and enforce response timeframes. The bill also requires reports from MedPAC, GAO, CMS, and ONC to monitor and analyze implementation.

Opponents' View#

No publicly available information.