H.R. 3514

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3514 Introduced in House (IH)]

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119th CONGRESS
1st Session
H. R. 3514

To amend title XVIII of the Social Security Act to establish 
requirements with respect to the use of prior authorization under 
Medicare Advantage plans.

_______________________________________________________________________

IN THE HOUSE OF REPRESENTATIVES

May 20, 2025

Mr. Kelly of Pennsylvania (for himself, Ms. DelBene, Mr. Joyce of 
Pennsylvania, Mr. Bera, Ms. Van Duyne, Ms. Chu, Mr. Crenshaw, Ms. 
Clarke of New York, Mr. Murphy, Ms. Moore of Wisconsin, Mr. Balderson, 
Ms. Schrier, Mr. Yakym, Ms. Sewell, Mrs. Harshbarger, Mr. Larson of 
Connecticut, Mr. Carey, Mr. Evans of Pennsylvania, Ms. Malliotakis, Mr. 
Beyer, Ms. Tenney, Ms. Tokuda, Mrs. Miller of West Virginia, Ms. 
Stevens, Mr. Fitzpatrick, Mr. Costa, Mr. Smucker, Ms. Pressley, Mr. 
LaHood, Mr. Davis of North Carolina, Mr. Meuser, Mr. Pocan, Ms. 
Salazar, Mr. Fields, Mr. Bacon, Mr. Foster, Mr. Mann, Ms. Brownley, Mr. 
Ciscomani, Mr. Conaway, Mr. Finstad, Ms. Bonamici, Mr. Shreve, Ms. 
Norton, Mrs. Kiggans of Virginia, Mr. Deluzio, Mr. Thompson of 
Pennsylvania, Mr. Mrvan, Mr. Moulton, Mr. Case, Ms. McBride, Ms. Ross, 
Ms. Budzinski, Mr. Quigley, Mr. Sorensen, Mr. McGarvey, Ms. Davids of 
Kansas, Ms. Brown, Mr. Crow, Mr. Torres of New York, Ms. Wasserman 
Schultz, Mr. Stanton, Mr. Levin, Mr. Keating, Ms. Johnson of Texas, Mr. 
Vicente Gonzalez of Texas, Ms. Goodlander, Ms. Craig, Mr. Goldman of 
New York, Ms. Barragan, Ms. Balint, Mr. Ryan, Ms. Houlahan, and Mrs. 
Miller-Meeks) introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall 
within the jurisdiction of the committee concerned

_______________________________________________________________________

A BILL

To amend title XVIII of the Social Security Act to establish 
requirements with respect to the use of prior authorization under 
Medicare Advantage plans.

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``Improving Seniors' Timely Access to 
Care Act of 2025''.

SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR 
AUTHORIZATION UNDER MEDICARE ADVANTAGE PLANS.

(a) In General.--Section 1852 of the Social Security Act (42 U.S.C. 
1395w-22) is amended by adding at the end the following new subsection:
``(o) Prior Authorization Requirements.--
``(1) In general.--In the case of a Medicare Advantage plan 
that imposes any prior authorization requirement with respect 
to any applicable item or service (as defined in paragraph (5)) 
during a plan year, such plan shall--
``(A) beginning with plan years beginning on or 
after January 1, 2028--
``(i) establish the electronic prior 
authorization program described in paragraph 
(2); and
``(ii) meet the enrollee protection 
standards specified pursuant to paragraph (4); 
and
``(B) beginning with plan years beginning on or 
after January 1, 2027, meet the transparency 
requirements specified in paragraph (3).
``(2) Electronic prior authorization program.--
``(A) In general.--For purposes of paragraph 
(1)(A), the electronic prior authorization program 
described in this paragraph is a program that provides 
for the secure electronic transmission of--
``(i) a prior authorization request from a 
provider or supplier to a Medicare Advantage 
plan with respect to an applicable item or 
service to be furnished to an individual and a 
response, in accordance with this paragraph, 
from such plan to such provider or supplier; 
and
``(ii) any supporting documentation 
relating to such request or response.
``(B) Electronic transmission.--
``(i) Exclusions.--For purposes of this 
paragraph, a facsimile, a proprietary payer 
portal that does not meet standards specified 
by the Secretary, or an electronic form shall 
not be treated as an electronic transmission 
described in subparagraph (A).
``(ii) Standards.--An electronic 
transmission described in subparagraph (A) 
shall comply with applicable technical 
standards and other requirements to promote the 
standardization and streamlining of electronic 
transactions adopted by the Secretary.
``(3) Transparency requirements.--
``(A) In general.--For purposes of paragraph 
(1)(B), the transparency requirements specified in this 
paragraph are, with respect to a Medicare Advantage 
plan, the following:
``(i) The plan, annually and in a manner 
specified by the Secretary, shall submit to the 
Secretary the following information:
``(I) A list of all applicable 
items and services that were subject to 
a prior authorization requirement under 
the plan during the previous plan year.
``(II) The percentage and number of 
specified requests (as defined in 
subparagraph (F)) approved during the 
previous plan year by the plan in an 
initial determination and the 
percentage and number of specified 
requests denied during such plan year 
by such plan in an initial 
determination (both in the aggregate 
and categorized by each item and 
service).
``(III) The percentage and number 
of specified requests that were denied 
during the previous plan year by the 
plan in an initial determination and 
that were subsequently appealed.
``(IV) The number of appeals of 
specified requests resolved during the 
preceding plan year, and the percentage 
and number of such resolved appeals 
that resulted in approval of the 
furnishing of the item or service that 
was the subject of such request, 
categorized by each applicable item and 
service and categorized by each level 
of appeal (including judicial review).
``(V) The percentage and number of 
specified requests that were denied, 
and the percentage and number of 
specified requests that were approved, 
by the plan during the previous plan 
year through the utilization of 
decision support technology, artificial 
intelligence technology, machine-
learning technology, clinical decision-
making technology, or any other 
technology specified by the Secretary.
``(VI) The average and the median 
amount of time (in hours) that elapsed 
during the previous plan year between 
the submission of a specified request 
to the plan and a determination by the 
plan with respect to such request for 
each such item and service, excluding 
any such requests that were not 
submitted with the medical or other 
documentation required to be submitted 
by the plan.
``(VII) The percentage and number 
of specified requests that were 
excluded from the calculation described 
in subclause (VI) based on the plan's 
determination that such requests were 
not submitted with the medical or other 
documentation required to be submitted 
by the plan.
``(VIII) Information on each 
occurrence during the previous plan 
year in which, during a surgical or 
medical procedure involving the 
furnishing of an applicable item or 
service with respect to which such plan 
had approved a prior authorization 
request, the provider or supplier 
furnishing such item or service 
determined that a different or 
additional item or service was 
medically necessary, including a 
specification of whether such plan 
subsequently approved the furnishing of 
such different or additional item or 
service.
``(IX) A disclosure and description 
of any technology described in 
subclause (V) that the plan utilized 
during the previous plan year in making 
determinations with respect to 
specified requests.
``(X) The number of grievances (as 
described in subsection (f)) received 
by such plan during the previous plan 
year that were related to a prior 
authorization requirement.
``(XI) Such other information as 
the Secretary determines appropriate.
``(ii) The plan shall provide--
``(I) to each provider or supplier 
who seeks to enter into a contract with 
such plan to furnish applicable items 
and services under such plan, the list 
described in clause (i)(I) and any 
policies or procedures used by the plan 
for making determinations with respect 
to prior authorization requests;
``(II) to each such provider and 
supplier that enters into such a 
contract, access to the criteria used 
by the plan for making such 
determinations and an itemization of 
the medical or other documentation 
required to be submitted by a provider 
or supplier with respect to such a 
request; and
``(III) to an enrollee of the plan, 
upon request, access to the criteria 
used by the plan for making 
determinations with respect to prior 
authorization requests for an item or 
service.
``(B) Option for plan to provide certain additional 
information.--As part of the information described in 
subparagraph (A)(i) provided to the Secretary during a 
plan year, a Medicare Advantage plan may elect to 
include information regarding the percentage and number 
of specified requests made with respect to an 
individual and an item or service that were denied by 
the plan during the preceding plan year in an initial 
determination based on such requests failing to 
demonstrate that such individuals met the clinical 
criteria established by such plan to receive such items 
or services.
``(C) Regulations.--The Secretary shall, through 
notice and comment rulemaking, establish requirements 
for Medicare Advantage plans regarding the provision 
of--
``(i) access to criteria described in 
subparagraph (A)(ii)(II) to providers of 
services and suppliers in accordance with such 
subparagraph; and
``(ii) access to such criteria to enrollees 
in accordance with subparagraph (A)(ii)(III).
``(D) Publication of information.--The Secretary 
shall publish information described in subparagraph 
(A)(i) and subparagraph (B) on a public website of the 
Centers for Medicare & Medicaid Services. Such 
information shall be so published on an individual plan 
level and may in addition be aggregated in such manner 
as determined appropriate by the Secretary.
``(E) Medpac report.--Not later than 3 years after 
the date information is first submitted under 
subparagraph (A)(i), the Medicare Payment Advisory 
Commission shall submit to Congress a report on such 
information that includes a descriptive analysis of the 
use of prior authorization. As appropriate, the 
Commission should report on statistics including the 
frequency of appeals and overturned decisions. The 
Commission shall provide recommendations, as 
appropriate, on any improvement that should be made to 
the electronic prior authorization programs of Medicare 
Advantage plans.
``(F) Specified request defined.--For purposes of 
this paragraph, the term `specified request' means a 
prior authorization request made with respect to an 
applicable item or service.
``(4) Enrollee protection standards.--For purposes of 
paragraph (1)(A)(ii), with respect to the use of prior 
authorization by Medicare Advantage plans for applicable items 
and services, the enrollee protection standards specified in 
this paragraph are--
``(A) the adoption of transparent prior 
authorization programs developed in consultation with 
enrollees and with providers and suppliers with 
contracts in effect with such plans for furnishing such 
items and services under such plans;
``(B) allowing for the waiver or modification of 
prior authorization requirements based on the 
performance of such providers and suppliers in 
demonstrating compliance with such requirements, such 
as adherence to evidence-based medical guidelines and 
other quality criteria; and
``(C) conducting annual reviews of such items and 
services for which prior authorization requirements are 
imposed under such plans through a process that takes 
into account input from enrollees and from providers 
and suppliers with such contracts in effect and is 
based on consideration of prior authorization data from 
previous plan years and analyses of current coverage 
criteria.
``(5) Applicable item or service defined.--For purposes of 
this subsection, the term `applicable item or service' means, 
with respect to a Medicare Advantage plan, any item or service 
for which benefits are available under such plan, other than a 
covered part D drug.
``(6) Reports to congress.--
``(A) GAO.--Not later than January 1, 2032, the 
Comptroller General of the United States shall submit 
to Congress a report containing an evaluation of the 
implementation of the requirements of this subsection 
and an analysis of issues in implementing such 
requirements faced by Medicare Advantage plans.
``(B) HHS.--
``(i) The secretary.--Not later than the 
end of the fifth plan year beginning after the 
date of the enactment of this subsection, and 
biennially thereafter through the date that is 
10 years after such date of enactment, the 
Secretary shall submit to Congress a report 
containing a description of the information 
submitted under paragraph (3)(A)(i) during--
``(I) in the case of the first such 
report, the fourth plan year beginning 
after the date of the enactment of this 
subsection; and
``(II) in the case of a subsequent 
report, the 2 plan years preceding the 
year of the submission of such report.
``(ii) CMS.--Not later than January 1, 
2028, the Centers for Medicare & Medicaid 
Services and the Office of National Coordinator 
for Health Information Technology shall submit 
to Congress and publish on the internet website 
of the Centers for Medicare & Medicaid Services 
a report that--
``(I) defines the term `real-time 
decision' and details how the 
definition for such term may be updated 
based on any technological advances;
``(II) using the data submitted to 
the Secretary under paragraph 
(3)(A)(i), details a process for real-
time decisions for routinely approved 
items and services for purposes of the 
electronic prior authorization program 
described in paragraph (2); and
``(III) includes an analysis of--
``(aa) items and services 
that are routinely approved;
``(bb) items and services 
identified in item (aa) that 
could be eligible for real-time 
decisions;
``(cc) whether establishing 
real-time decisions for such 
items and services could--

``(AA) improve 
enrollee access to 
benefits under this 
part;

``(BB) produce 
operational 
efficiencies for 
providers and suppliers 
and Medicare Advantage 
plans; and

``(CC) reduce 
health disparities for 
Medicare Advantage 
enrollees in rural and 
low-income communities; 
and

``(dd) how determinations 
of routinely approved items and 
services made solely through 
automation and artificial 
intelligence by Medicare 
Advantage plans impact patient 
access, including disparities 
in access for rural and low-
income beneficiaries.''.
(b) Providing the Secretary Authority To Enforce Timely Responses 
for All Prior Authorization Requests Submitted Under Part C.--Section 
1852(g) of the Social Security Act (42 U.S.C. 1395w-22(g)) is amended--
(1) in paragraph (1)(A), by inserting ``and in accordance 
with any timeframe established by the Secretary under paragraph 
(6)'' after ``paragraph (3)'';
(2) in paragraph (3)(B)(iii), by inserting ``(with respect 
to prior authorization requests submitted on or after the first 
day of the third plan year beginning after the date of the 
enactment of the Improving Seniors' Timely Access to Care Act 
of 2025, any timeframe established by the Secretary under 
paragraph (6))'' after ``72 hours''; and
(3) by adding at the end the following new paragraph:
``(6) Timeframe for response to prior authorization 
requests.--Subject to paragraph (3), the Secretary may 
establish, for purposes of an organization determination made 
with respect to a prior authorization request for an item or 
service to be furnished to an individual, timeframes, such as 
24 hours, for the organization to notify the enrollee (and the 
physician involved, as appropriate) of such determination for--
``(A) a request for expedited determination 
described in paragraph (3)(A);
``(B) a real time decision for routinely approved 
items and services; and
``(C) any other prior authorization request.''.
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