,i  #aafth ,,congress  #ast ,session    
,h4 ,r4 #cajg  ,,in ,,the ,,house ,,of  
,,representatives  ,june #e1 #bjai,ms4  
,del,bene 7for herself1 ,mr4 ,kelly of  
,pennsylvania1 ,mr4 ,marshall1 and ,mr4 
,bera7 introduced the following bill2   
which was referred to the ,committee on 
,ways and ,means1 and in addition to the
 ,committee on ,energy and ,commerce1   
for a period to be subsequently         
determined by the ,speaker1 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
 plans1 and for other purposes4  #a4    
,short title ,this ,act may be cited as 
the ,improving ,seniors' ,timely ,access
 to ,care ,act of #bjai4  #b4 ,sense of 
,congress ,it is the sense of ,congress 
that--  7#a7 use of prior authorization 
should be streamlined through electronic

 transmissions for coverage of covered  
services for individuals enrolled in    
federally funded programs such as       
,medicare1 ,medicaid1 and federally     
contracted managed care plans to improve
 patient access to medically appropriate
 services and reduce administrative     
burden through automation informed by   
clinical decision support2  7#b7 there  
should be increased transparency for    
beneficiaries and providers and         
increased oversight by the ,centers for 
,medicare  ,medicaid ,services on the   
processes used for prior authorization2 
and  7#c7 prior authorization is a tool 
that can be used to responsibly prevent 
unnecessary care and promote safe and   
evidence-based care4  #c4 ,establishing 
requirements with respect to the use of 
prior authorization under ,medicare     
,advantage plans  7a7 ,in general       
,section #aheb of the ,social ,security 
,act 7#db ,u4,s4,c4 #aciew-#bb7 is      
amended by adding at the end the        
following new subsection3  7o7 ,prior   

authorization requirements  7#a7 ,in    
general ,in the case of a ,medicare     
,advantage plan that imposes any prior  
authorization requirement with respect  
to any benefit1 such plan shall1        
beginning with the first plan year      
beginning on or after the date of the   
enactment of this subsection--  7,a7    
comply with the prohibition described in
 paragraph 7#b72  7,b7 establish the    
electronic prior authorization program  
described in paragraph 7#c72  7,c7 meet 
the transparency requirements specified 
in paragraph 7#d72 and  7,d7 meet the   
beneficiary protection standards        
specified pursuant to paragraph 7#e74   
7#b7 ,prohibition on prior authorization
 with respect to certain items and      
services ,a ,medicare ,advantage plan   
may not impose any additional prior     
authorization requirement with respect  
to any surgical procedure or otherwise  
invasive procedure 7as defined by the   
,secretary71 and any item furnished as  
part of such surgical or invasive       

procedure1 if such procedure 7or item7  
is furnished during the peroperative    
period of a procedure for which--  7,a7 
prior authorization was received from   
such plan before such surgical or       
otherwise invasive procedure 7or item   
furnished as part of such surgical or   
otherwise invasive procedure7 was       
furnished2 or  7,b7 prior authorization 
was not required by such plan4  7#c7    
,electronic prior authorization program 
7,a7 ,in general ,for purposes of       
paragraph 7#a77;,b71 the electronic     
prior authorization program described in
 this paragraph is a prior authorization
 process implemented by a ,medicare     
,advantage plan that provides for the   
secure electronic transmission of--  7i7
 a prior authorization request from a   
health care professional to such plan   
with respect to an item or service to be
 furnished to an individual1 including  
such clinical information as the        
professional determines appropriate to  
support the furnishing of such item or  

service to such individual2 and  7ii7 a 
response1 in accordance with this       
paragraph1 from such plan to such       
professional4  7,b7 ,electronic         
transmission  7i7 ,exclusions ,for      
purposes of this paragraph1 a facsimile1
 a proprietary payer portal that does   
not meet standards specified by the     
,secretary1 or an electronic form shall 
not be treated as an electronic         
transmission described in subparagraph  
7,a74  7ii7 ,standards  7,i7 ,in general
 ,in order to ensure appropriate        
clinical outcome for individuals1 for   
purposes of this paragraph1 an          
electronic transmission described in    
subparagraph 7,a7 shall comply with     
technical standards adopted by the      
,secretary in consultation with         
standard-setting organizations          
determined appropriate by the           
,secretary1 health care professionals1  
,,ma organizations1 and health          
information technology software vendors4
 ,in adopting such standards1 the       

,secretary shall ensure that such       
transmissions support attachments       
containing applicable clinical          
information and shall prioritize the    
adoption of standards that encourage    
integration of the electronic prior     
authorization program into established  
electronic health record systems4       
7,,ii7 ,transaction standard ,the       
,secretary shall include in the         
standards adopted under subclause 7,i7 a
 standard with respect to the           
transmission of attachments described in
 such subclause1 and data elements and  
operating rules for such transmission1  
consistent with health care industry    
standards4  7,c7 ,real-time decisions   
7i7 ,in general ,the program described  
in subparagraph 7,a7 shall provide for  
real-time decisions 7as defined by the  
,secretary7 with respect to requests    
identified by the ,secretary pursuant to
 clause 7ii7 for a plan year if such    
requests contain all information        
required by an ,,ma plan to evaluate the

 criteria described in paragraph        
7#d77;,a77iii77,,ii74  7ii7             
,identification of requests ,for        
purposes of clause 7i7 and with respect 
to a plan year1 the ,secretary shall    
identify1 not later than the date on    
which the initial announcement described
 in section #ahec7;b77#a77;,b77i7 for   
such plan year is required to be        
announced1 items and services for which 
prior authorization requests are        
routinely approved4  7iii7 ,data        
collection and consultation with        
relevant eligible professional          
organizations and relevant stakeholders 
,in identifying requests for a year     
under clause 7ii71 the ,secretary shall 
use the information described in        
paragraph 7#d77;,a7 7if available7 and  
shall issue a request for information   
from providers1 suppliers1 patient      
advocacy organizations1 and other       
stakeholders4  7#d7 ,transparency       
requirements  7,a7 ,in general ,for     
purposes of paragraph 7#a77;,c71 the    

transparency requirements specified in  
this paragraph are1 with respect to a   
,medicare ,advantage plan1 the          
following3  7i7 ,the plan1 not less     
frequently than annually and at a time  
and in a manner specified by the        
,secretary1 shall submit to the         
,secretary the following information3   
7,i7 ,a list of all items and services  
that are described in subsection        
7a77#a77;,b7 that are subject to a prior
 authorization requirement under the    
plan4  7,,ii7 ,the percentage of prior  
authorization requests approved during  
the previous plan year by the plan with 
respect to each such item and service4  
7,,iii7 ,the percentage of such requests
 that were initially denied and that    
were subsequently appealed1 and the     
percentage of such appealed requests    
that were overturned1 with respect to   
each such item and service4  7,,iv7 ,the
 average and the median amount of time  
7in hours7 that elapsed during the      
previous plan year between the          

submission of such a request to the plan
 and a determination by the plan with   
respect to such request for each such   
item and service1 excluding any such    
requests that did not contain all       
information required to be submitted by 
the plan4  7,v7 ,such other information 
as the ,secretary determines appropriate
 after consultation with and comment    
from stakeholders4  7ii7 ,the plan shall
 publish the information described in   
clause 7i7 annually before open         
enrollment on a publicly available      
website4 ,such plan shall provide the   
address of such website in any          
enrollment materials distributed by the 
plan and shall update such website in a 
timely manner4  7iii7 ,the plan shall   
provide-- 7,i7 along with contract      
materials for any provider or supplier  
who seeks to participate under the plan1
 the list described in clause 7i77,i7   
and any policies or procedures used by  
the plan for making determinations with 
respect to prior authorization requests2

 and  7,,ii7 to each provider and       
supplier participating under the plan1  
access to the criteria used by the plan 
for making such determinations1         
including an itemization of the medical 
or other documentation required to be   
submitted by a provider or supplier with
 respect to such a request1 except to   
the extent that provision of access to  
such criteria would disclose proprietary
 information of such plan1 as determined
 by the ,secretary4  7,b7 ,report to    
,congress ,not later than the end of the
 second plan year beginning on or after 
the date of the enactment of this       
subsection1 and biennially thereafter1  
the ,secretary shall submit to ,congress
 a report describing the information    
submitted under subparagraph 7,a77i7    
with respect to--  7i7 in the case of   
the first such report1 the first plan   
year beginning on or after such date2   
and  7ii7 in the case of a subsequent   
report1 the #b full plan years preceding
 the date of the submission of such     

report4  7#e7 ,beneficiary protection   
standards ,the ,secretary of ,health and
 ,human ,services shall1 through notice 
and comment rulemaking1 specify         
standards with respect to the use of    
prior authorization by ,,ma plans to    
ensure--  7,a7 that such plans adopt    
transparent programs developed in       
consultation with providers and         
suppliers participating under the plans 
that promote the modification of such   
requirements based on the performance of
 such providers and suppliers with      
respect to adherence to evidence-based  
medical guidelines and other quality    
criteria2  7,b7 that such plans conduct 
annual reviews of items and services for
 which prior authorization requirements 
are imposed under such plans through a  
process that takes into account input   
from participating providers and        
suppliers and is based on analysis of   
past prior authorization requests and   
current clinical criteria2  7,c7        
continuity of care for individuals      

transitioning to1 or between1 coverage  
under such plans in order to minimize   
any disruption to ongoing treatment     
attributable to prior authorization     
requirements under such plans2  7,d7    
that such plans make timely prior       
authorization determinations1 provide   
rationales for denials1 and ensure      
requests are reviewed by qualified      
medical personnel2 and  7,e7 that plans 
assist providers and suppliers in       
submitting the information necessary to 
enable the plan to make a prior         
authorization determination in a timely 
manner4  4  7b7 ,determination          
clarification ,section                  
#aheb7;g77#a77;,a7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acibw-#bb7;g77#a77;,a77 is amended by  
inserting 7including any decision made  
with respect to a prior authorization   
request for such service7 after section4