,,ii #aafth ,,congress #b;d ,session ,s4 #ejdd ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #ag1 #bjbj,mr4 ,brown 7for himself and ,mr4 ,thune7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,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 purposes #a4 ,short title ,this ,act may be cited as the ,improving ,seniors' ,timely ,access to ,care ,act of #bjbj4 #b4 ,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 ,beginning with the second plan year beginning after the date of the enactment of this subsection1 in the case of a ,medicare ,advantage plan that imposes any prior authorization requirement with respect to any applicable item or service 7other than a covered part ,d drug7 during a plan year1 such plan shall-- 7,a7 establish the electronic prior authorization program described in paragraph 7#b7 and issue real-time decisions with respect to prior authorization requests for items and services identified by the ,secretary under subparagraph 7,c77ii7 of such paragraph2 7,b7 meet the transparency requirements specified in paragraph 7#c72 and 7,c7 meet the beneficiary protection standards specified pursuant to paragraph 7#d74 7#b7 ,electronic prior authorization program 7,a7 ,in general ,for purposes of paragraph 7#a77;,a71 the electronic prior authorization program described in this paragraph is a program that provides for the secure electronic transmission of-- 7i7 a prior authorization request from a health care professional to a ,medicare ,advantage plan with respect to an applicable item or service to be furnished to an individual1 including such clinical information necessary to evidence medical necessity2 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 ,medicare ,advantage organizations1 and health information technology software vendors4 ,in adopting such standards with respect to which an electronic transmission described in subparagraph 7,a7 shall comply1 the ,secretary shall ensure that such transmissions support attachments containing applicable clinical information and shall prioritize the adoption of standards that support integration with interoperable health information technology certified under a program of voluntary certification kept or recognized by the ,national ,coordinator for ,health ,information ,technology consistent with section #cjja7;c77#e7 of the ,public ,health ,service ,act4 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 ,secretary in accordance with clause 7iv77 by a ,medicare ,advantage plan with respect to prior authorization requests for applicable items and services identified by the ,secretary pursuant to clause 7ii7 for a plan year if such requests contain all documentation described in paragraph 7#c77;,a77ii77,,ii7 required by such plan4 7ii7 ,identification of requests ,for purposes of clause 7i7 and with respect to a period of #b plan years1 the ,secretary shall identify1 not later than the date on which the initial announcement described in section #ahec7;b77#a77;,b77i7 for the first plan year of such period is required to be announced1 applicable items and services for which prior authorization requests are routinely approved1 and shall update the identification of such items and services for each subsequent period of #b plan years4 7iii7 ,data collection and consultation with relevant eligible professional organizations and relevant stakeholders ,the ,secretary shall use the information described in paragraph 7#c77;,a7 7if available7 and shall issue a request for information from ,medicare ,advantage plans1 providers1 suppliers1 beneficiary advocacy organizations1 consumer organizations1 and other stakeholders for purposes of identifying requests for a period under clause 7ii74 7iv7 ,definition of real-time decision 7,i7 ,in general ,in establishing the definition of a real-time decision for purposes of clause 7i71 the ,secretary shall take into account current medical practice1 technology1 health care industry standards1 and other relevant information and factors to ensure the accurate and timely furnishing of items and services to individuals4 7,,ii7 ,update ,the ,secretary shall update1 not less often than once every #b years1 the definition of a real-time decision for purposes of clause 7i71 taking into account changes in medical practice1 changes in technology1 changes in health care industry standards1 and other relevant information1 such as the information submitted by ,medicare ,advantage plans under paragraph 7#c77;,a77i71 and factors to ensure the accurate and timely furnishing of items and services to individuals4 7v7 ,implementation ,the ,secretary shall use notice and comment rulemaking1 which may include use of the annual call letter process under this part1 for each of the following3 7,i7 ,establishing the definition of a real-time decision for purposes of clause 7i74 7,,ii7 ,updating such definition pursuant to clause 7iv77,,ii74 7,,iii7 ,identifying applicable items or services pursuant to clause 7ii7 for the initial period of #b plan years as described in such clause4 7,,iv7 ,updating the identification of such items and services for each subsequent period of #b plan years as described in such clause4 7#c7 ,transparency requirements 7,a7 ,in general ,for purposes of paragraph 7#a77;,b71 the transparency requirements specified in this paragraph are1 with respect to a ,medicare ,advantage plan1 the following3 7i7 ,the plan1 annually and in a manner specified by the ,secretary1 shall submit to the ,secretary the following information3 7,i7 ,a list of all applicable 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 in an initial determination with respect to each such item and service4 7,,iii7 ,the percentage of such requests that were initially denied and that were subsequently appealed in any manner1 and the percentage of such appealed requests that were overturned1 with respect to each such item and service1 broken down by each stage of appeal 7including judicial review74 ,the plan may include information regarding the number of initial denials due to request submissions that did not meet clinical evidence standards4 7,,iv7 ,the percentage of such requests that were denied and the percentage of the total number of denied requests that were denied as a result of decision support technology or other clinical decision-making tools4 7,v7 ,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,,vi7 ,a list that includes a description of each occurrence during the previous plan year in which the plan made a determination to approve or deny an item or service in the case where a provider furnished an additional or differing item or service during the peroperative period of a surgical or otherwise invasive procedure that such provider determined was medically necessary4 7,,vii7 ,a disclosure and description of any software decision-making tools the plan utilizes in making determinations with respect to such requests4 7,,viii7 ,such other information as the ,secretary determines appropriate4 7ii7 ,the plan shall provide-- 7,i7 to each provider or supplier who seeks to enter into a contract with such plan to furnish applicable items and services under such 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 7,,ii7 to each such provider and supplier who does enter into such a contract1 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 plan2 and 7,,iii7 to each beneficiary subject to prior authorization under the plan1 access to the criteria used by the plan for making such determinations1 except to the extent that provision of access to such criteria would disclose proprietary information of such plan4 7,b7 ,regulations ,the ,secretary shall1 through notice and comment rulemaking1 provide guidance to ,medicare ,advantage plans regarding-- 7i7 the establishment of criteria described in subparagraph 7,a77ii77,,ii7 and access to such criteria by providers and suppliers in accordance with such subparagraph2 and 7ii7 access to such criteria by beneficiaries in accordance with subparagraph 7,a77ii77,,iii74 7,c7 ,med,pac report ,not later than #c years after the date information is first submitted under subparagraph 7,a77i71 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report on such information that includes a descriptive analysis of the use of prior authorization4 ,as appropriate1 the ,commission should report on statistics including the frequency of appeals and overturned decisions4 ,the ,commission shall provide recommendations1 as appropriate1 on any improvement that should be made to the electronic prior authorization programs of ,medicare ,advantage plans4 7#d7 ,beneficiary protection standards ,the ,secretary of ,health and ,human ,services shall1 through notice and comment rulemaking1 specify requirements with respect to the use of prior authorization by ,medicare ,advantage plans for applicable items and services to ensure-- 7,a7 that such plans adopt transparent prior authorization programs developed in consultation with providers and suppliers with contracts in effect with such plans for furnishing such items and services under such plans that allow for the modification of prior authorization 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 such items and services for which prior authorization requirements are imposed under such plans through a process that takes into account input from providers and suppliers with such contracts in effect and is based on analysis of past prior authorization requests and current coverage and 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 such plans provide information on the appeals process to the beneficiary when denying any request for prior authorization with respect to an item or service4 7#e7 ,applicable item or service ,for purposes of this subsection1 the term applicable item or service means1 with respect to a ,medicare ,advantage plan1 any item or service for which benefits are available under such plan1 other than a covered part ,d drug4 7#f7 ,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 thereafter through the date that is #aj years after such date of enactment1 the ,secretary shall submit to ,congress a report containing an evaluation of the implementation of the requirements of this subsection1 an analysis of an issues in implementing such requirements faced by ,medicare ,advantage plans1 and a description of the information submitted under paragraph 7#c77;,a77i7 with respect to-- 7,a7 in the case of the first such report1 such second plan year2 and 7,b7 in the case of a subsequent report1 the #b full plan years preceding the date of the submission of such report4 4 7b7 ,determination clarification ,section #aheb7;g77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#a77;,a77 is amended by inserting 7including any decision made with respect to a prior authorization request for such service7 after section4