Bipartisan, Bicameral Prior Authorization Legislation Reintroduced
Members of Congress have recently reintroduced bipartisan, bicameral legislation aimed at simplifying prior authorization (PA) within the Medicare Advantage (MA) program.
The Improving Seniors' Timely Access to Care Act (S.4532/H.R 8702) is sponsored by Senators Roger Marshall, MD (R-Kan.), Krysten Sinema (I-Ariz.), John Thune (R-S.D.), and Sherrod Brown (D-Ohio), and Representatives Mike Kelly (R-Pa.), Suzan DelBene (D-Wash.), Larry Bucshon, MD (R-Ind.), and Ami Bera, MD (D-Calif.).
HRS and nearly 400 national and state organizations endorsed this legislation upon introduction. The legislation builds upon regulatory changes made by CMS effective January 1, 2024, which incorporated provisions from a prior version of the bill that unanimously passed the House of Representatives last Congress but did not advance in the Senate after receiving a sizeable cost estimate.
The current bill codifies the regulatory changes and would establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments; an increase in transparency around MA prior authorization requirements and use; clarification of CMS' authority to establish timeframes for electronic PA (e-PA) requests, including expedited determinations; real-time decisions for routinely approved items and services and other PA requests; an expansion of beneficiary protections to improve enrollee experiences and outcomes; and a requirement that the U.S. Department of Health and Human Services and other agencies report to Congress on program integrity efforts and other ways to further improve the e-PA process.
The bill sponsors worked to ensure that the additional provisions add minimal or no cost in the hope of securing passage before the end of the year.