,i  #aaf? ,,congress  #a/ ,session  ,h4 
,r4 #cajg  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,june #e1 #bjai,ms4   
,del,bene 7= h]self1 ,mr4 ,kelly (      
,p5nsylvania1 ,mr4 ,m>%all1 & ,mr4 ,b]a7
 introduc$ ! foll[+ bill2 :i* 0 ref]r$  
to ! ,committee on ,ways & ,means1 & 9  
addition to ! ,committee on ,en]gy &    
,comm]ce1 = a p]iod to be subsequ5tly   
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d title ,,xviii ( !     
,social ,security ,act to e/abli%       
requirem5ts ) respect to ! use ( prior  
au?orization "u ,m$ic>e ,advantage      
plans1 & = o!r purposes4  #a4 ,%ort     
title ,?is ,act may be cit$ z ! ,improv+
 ,s5iors' ,timely ,access to ,c>e ,act (
 #bjai4  #b4 ,s5se ( ,congress ,x is !  
s5se ( ,congress t--  7#a7 use ( prior  
au?orization %\ld be /reaml9$ ?r\gh     
electronic transmissions = cov]age (    
cov]$ s]vices = individuals enroll$ 9   
f$]ally fund$ programs su* z ,m$ic>e1   

,m$icaid1 & f$]ally contract$ manag$ c>e
 plans to improve pati5t access to      
m$ically appropriate s]vices & r$uce    
adm9i/rative burd5 ?r\gh automation     
in=m$ by cl9ical decision support2  7#b7
 !re %\ld be increas$ transp>5cy =      
b5efici>ies & provid]s & increas$       
ov]sight by ! ,c5t]s = ,m$ic>e  ,m$icaid
 ,s]vices on ! processes us$ = prior    
au?orization2 &  7#c7 prior au?orization
 is a tool t c be us$ to responsibly    
prev5t unnecess>y c>e & promote safe &  
evid5ce-bas$ c>e4  #c4 ,e/abli%+        
requirem5ts ) respect to ! use ( prior  
au?orization "u ,m$ic>e ,advantage plans
  7a7 ,9 g5]al ,section #aheb ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#bb7 is am5d$ by add+ at ! end ! 
foll[+ new subsection3  7o7 ,prior      
au?orization requirem5ts  7#a7 ,9 g5]al 
,9 ! case ( a ,m$ic>e ,advantage plan t 
imposes any prior au?orization          
requirem5t ) respect to any b5efit1 su* 
plan %all1 beg9n+ ) ! fir/ plan ye>     
beg9n+ on or aft] ! date ( ! enactm5t ( 

?is subsection--  7,a7 comply ) !       
prohibition describ$ 9 p>agraph 7#b72   
7,b7 e/abli% ! electronic prior         
au?orization program describ$ 9 p>agraph
 7#c72  7,c7 meet ! transp>5cy          
requirem5ts specifi$ 9 p>agraph 7#d72 & 
7,d7 meet ! b5efici>y protection /&>ds  
specifi$ pursuant to p>agraph 7#e74     
7#b7 ,prohibition on prior au?orization 
) respect to c]ta9 items & s]vices ,a   
,m$ic>e ,advantage plan may n impose any
 additional prior au?orization          
requirem5t ) respect to any surgical    
proc$ure or o!rwise invasive proc$ure 7z
 def9$ by ! ,secret>y71 & any item      
furni%$ z "p ( su* surgical or invasive 
proc$ure1 if su* proc$ure 7or item7 is  
furni%$ dur+ ! p]op]ative p]iod ( a     
proc$ure = :i*--  7,a7 prior            
au?orization 0 receiv$ f su* plan be=e  
su* surgical or o!rwise invasive        
proc$ure 7or item furni%$ z "p ( su*    
surgical or o!rwise invasive proc$ure7 0
 furni%$2 or  7,b7 prior au?orization 0 
n requir$ by su* plan4  7#c7 ,electronic

 prior au?orization program  7,a7 ,9    
g5]al ,= purposes ( p>agraph 7#a77;,b71 
! electronic prior au?orization program 
describ$ 9 ?is p>agraph is a prior      
au?orization process implem5t$ by a     
,m$ic>e ,advantage plan t provides = !  
secure electronic transmission (--  7i7 
a prior au?orization reque/ f a heal?   
c>e pr(essional to su* plan ) respect to
 an item or s]vice to be furni%$ to an  
individual1 includ+ su* cl9ical         
in=mation z ! pr(essional det]m9es      
appropriate to support ! furni%+ ( su*  
item or s]vice to su* individual2 &     
7ii7 a response1 9 accordance ) ?is     
p>agraph1 f su* plan to su* pr(essional4
  7,b7 ,electronic transmission  7i7    
,exclusions ,= purposes ( ?is p>agraph1 
a facsimile1 a propriet>y pay] portal t 
does n meet /&>ds specifi$ by !         
,secret>y1 or an electronic =m %all n be
 treat$ z an electronic transmission    
describ$ 9 subp>agraph 7,a74  7ii7      
,/&>ds  7,i7 ,9 g5]al ,9 ord] to ensure 
appropriate cl9ical outcome =           

individuals1 = purposes ( ?is p>agraph1 
an electronic transmission describ$ 9   
subp>agraph 7,a7 %all comply ) te*nical 
/&>ds adopt$ by ! ,secret>y 9           
consultation ) /&>d-sett+ organizations 
det]m9$ appropriate by ! ,secret>y1     
heal? c>e pr(essionals1 ,,ma            
organizations1 & heal? in=mation        
te*nology s(tw>e v5dors4 ,9 adopt+ su*  
/&>ds1 ! ,secret>y %all ensure t su*    
transmissions support atta*m5ts conta9+ 
applicable cl9ical in=mation & %all     
prioritize ! adoption ( /&>ds t enc\rage
 integration ( ! electronic prior       
au?orization program into e/abli%$      
electronic heal? record sy/ems4  7,,ii7 
,transaction /&>d ,! ,secret>y %all     
include 9 ! /&>ds adopt$ "u subclause   
7,i7 a /&>d ) respect to ! transmission 
( atta*m5ts describ$ 9 su* subclause1 & 
data elem5ts & op]at+ rules = su*       
transmission1 consi/5t ) heal? c>e      
indu/ry /&>ds4  7,c7 ,real-"t decisions 
7i7 ,9 g5]al ,! program describ$ 9      
subp>agraph 7,a7 %all provide = real-"t 

decisions 7z def9$ by ! ,secret>y7 )    
respect to reque/s id5tifi$ by !        
,secret>y pursuant to clause 7ii7 = a   
plan ye> if su* reque/s conta9 all      
in=mation requir$ by an ,,ma plan to    
evaluate ! crit]ia describ$ 9 p>agraph  
7#d77;,a77iii77,,ii74  7ii7             
,id5tification ( reque/s ,= purposes (  
clause 7i7 & ) respect to a plan ye>1 ! 
,secret>y %all id5tify1 n lat] ?an !    
date on :i* ! initial ann\ncem5t        
describ$ 9 section #ahec7;b77#a77;,b77i7
 = su* plan ye> is requir$ to be        
ann\nc$1 items & s]vices = :i* prior    
au?orization reque/s are r\t9ely        
approv$4  7iii7 ,data collection &      
consultation ) relevant eligible        
pr(essional organizations & relevant    
/akehold]s ,9 id5tify+ reque/s = a ye>  
"u clause 7ii71 ! ,secret>y %all use !  
in=mation describ$ 9 p>agraph 7#d77;,a7 
7if available7 & %all issue a reque/ =  
in=mation f provid]s1 suppli]s1 pati5t  
advocacy organizations1 & o!r           
/akehold]s4  7#d7 ,transp>5cy           

requirem5ts  7,a7 ,9 g5]al ,= purposes (
 p>agraph 7#a77;,c71 ! transp>5cy       
requirem5ts specifi$ 9 ?is p>agraph are1
 ) respect to a ,m$ic>e ,advantage plan1
 ! foll[+3  7i7 ,! plan1 n less         
frequ5tly ?an annually & at a "t & 9 a  
mann] specifi$ by ! ,secret>y1 %all     
submit to ! ,secret>y ! foll[+          
in=mation3  7,i7 ,a li/ ( all items &   
s]vices t are describ$ 9 subsection     
7a77#a77;,b7 t are subject to a prior   
au?orization requirem5t "u ! plan4      
7,,ii7 ,! p]c5tage ( prior au?orization 
reque/s approv$ dur+ ! previ\s plan ye> 
by ! plan ) respect to ea* su* item &   
s]vice4  7,,iii7 ,! p]c5tage ( su*      
reque/s t 7 initially d5i$ & t 7        
subsequ5tly appeal$1 & ! p]c5tage ( su* 
appeal$ reque/s t 7 ov]turn$1 ) respect 
to ea* su* item & s]vice4  7,,iv7 ,!    
av]age & ! m$ian am\nt ( "t 79 h\rs7 t  
elaps$ dur+ ! previ\s plan ye> betwe5 ! 
submission ( su* a reque/ to ! plan & a 
det]m9ation by ! plan ) respect to su*  
reque/ = ea* su* item & s]vice1 exclud+ 

any su* reque/s t did n conta9 all      
in=mation requir$ to be submitt$ by !   
plan4  7,v7 ,su* o!r in=mation z !      
,secret>y det]m9es appropriate aft]     
consultation ) & comm5t f /akehold]s4   
7ii7 ,! plan %all publi% ! in=mation    
describ$ 9 clause 7i7 annually be=e op5 
enrollm5t on a publicly available       
website4 ,su* plan %all provide !       
address ( su* website 9 any enrollm5t   
mat]ials di/ribut$ by ! plan & %all     
update su* website 9 a timely mann]4    
7iii7 ,! plan %all provide-- 7,i7 along 
) contract mat]ials = any provid] or    
suppli] :o seeks to p>ticipate "u !     
plan1 ! li/ describ$ 9 clause 7i77,i7 & 
any policies or proc$ures us$ by ! plan 
= mak+ det]m9ations ) respect to prior  
au?orization reque/s2 &  7,,ii7 to ea*  
provid] & suppli] p>ticipat+ "u ! plan1 
access to ! crit]ia us$ by ! plan = mak+
 su* det]m9ations1 includ+ an           
itemization ( ! m$ical or o!r           
docum5tation requir$ to be submitt$ by a
 provid] or suppli] ) respect to su* a  

reque/1 except to ! ext5t t provision ( 
access to su* crit]ia w\ld disclose     
propriet>y in=mation ( su* plan1 z      
det]m9$ by ! ,secret>y4  7,b7 ,report to
 ,congress ,n lat] ?an ! end ( ! second 
plan ye> beg9n+ on or aft] ! date ( !   
enactm5t ( ?is subsection1 & bi5nially  
!reaft]1 ! ,secret>y %all submit to     
,congress a report describ+ ! in=mation 
submitt$ "u subp>agraph 7,a77i7 )       
respect to--  7i7 9 ! case ( ! fir/ su* 
report1 ! fir/ plan ye> beg9n+ on or    
aft] su* date2 &  7ii7 9 ! case ( a     
subsequ5t report1 ! #b full plan ye>s   
prec$+ ! date ( ! submission ( su*      
report4  7#e7 ,b5efici>y protection     
/&>ds ,! ,secret>y ( ,heal? & ,human    
,s]vices %all1 ?r\gh notice & comm5t    
rulemak+1 specify /&>ds ) respect to !  
use ( prior au?orization by ,,ma plans  
to ensure--  7,a7 t su* plans adopt     
transp>5t programs develop$ 9           
consultation ) provid]s & suppli]s      
p>ticipat+ "u ! plans t promote !       
modification ( su* requirem5ts bas$ on !

 p]=mance ( su* provid]s & suppli]s )   
respect to adh]5ce to evid5ce-bas$      
m$ical guidel9es & o!r quality crit]ia2 
7,b7 t su* plans conduct annual reviews 
( items & s]vices = :i* prior           
au?orization requirem5ts are impos$ "u  
su* plans ?r\gh a process t takes into  
acc\nt input f p>ticipat+ provid]s &    
suppli]s & is bas$ on analysis ( pa/    
prior au?orization reque/s & curr5t     
cl9ical crit]ia2  7,c7 cont9uity ( c>e =
 individuals transition+ to1 or betwe51 
cov]age "u su* plans 9 ord] to m9imize  
any disruption to ongo+ treatm5t        
attributable to prior au?orization      
requirem5ts "u su* plans2  7,d7 t su*   
plans make timely prior au?orization    
det]m9ations1 provide rationales =      
d5ials1 & ensure reque/s are review$ by 
qualifi$ m$ical p]sonnel2 &  7,e7 t     
plans assi/ provid]s & suppli]s 9       
submitt+ ! in=mation necess>y to enable 
! plan to make a prior au?orization     
det]m9ation 9 a timely mann]4  4  7b7   
,det]m9ation cl>ification ,section      

#aheb7;g77#a77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acibw-#bb7;g77#a77;,a77 is am5d$ by    
ins]t+ 7includ+ any decision made )     
respect to a prior au?orization reque/ =
 su* s]vice7 aft] section4