,,ii #aagth ,,congress #b;d ,session ,h4 ,r4 #cagc ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,september #ae1 #bjbb,received ,,an ,,act ,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 #bjbb4 #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 ,in the case of a ,medicare ,advantage plan that imposes any prior authorization requirement with respect to any applicable item or service 7as defined in paragraph 7#e77 during a plan year1 such plan shall-- 7,a7 beginning with the third plan year beginning after the date of the enactment of this subsection-- 7i7 establish the electronic prior authorization program described in paragraph 7#b72 and 7ii7 meet the enrollee protection standards specified pursuant to paragraph 7#d72 and 7,b7 beginning with the fourth plan year beginning after the date of the enactment of this subsection1 meet the transparency requirements specified in paragraph 7#c74 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 provider of services or supplier to a ,medicare ,advantage plan with respect to an applicable item or service to be furnished to an individual and a response1 in accordance with this paragraph1 from such plan to such provider or supplier2 and 7ii7 any attachment relating to such request or response4 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 ,an electronic transmission described in subparagraph 7,a7 shall comply with-- 7,i7 applicable technical standards adopted by the ,secretary pursuant to section #aagc2 and 7,,ii7 other requirements to promote the standardization and streamlining of electronic transactions under this part specified by the ,secretary4 7iii7 ,deadline for specification of additional requirements ,not later than ,july #a1 #bjbc1 the ,secretary shall finalize requirements described in clause 7ii77,,ii74 7,c7 ,real-time decisions 7i7 ,in general ,subject to clause 7iv71 the program described in subparagraph 7,a7 shall provide for real-time decisions 7as defined by the ,secretary in accordance with clause 7v77 by a ,medicare ,advantage plan with respect to prior authorization requests for applicable items and services identified by the ,secretary pursuant to clause 7ii7 if such requests are submitted with all medical or other documentation required by such plan4 7ii7 ,identification of items and services 7,i7 ,in general ,for purposes of clause 7i71 the ,secretary shall identify1 not later than the date on which the initial announcement described in section #ahec7;b77#a77;,b77i7 for the third plan year beginning after the date of the enactment of this subsection is required to be announced1 applicable items and services for which prior authorization requests are routinely approved4 7,,ii7 ,updates ,the ,secretary shall consider updating the applicable items and services identified under subclause 7,i7 based on the information described in paragraph 7#c77;,a77i7 7if available and determined practicable to utilize by the ,secretary7 and any other information determined appropriate by the ,secretary not less frequently than biennially4 ,the ,secretary shall announce any such update that is to apply with respect to a plan year 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 announced4 7iii7 ,request for information ,the ,secretary shall issue a request for information for purposes of initially identifying applicable items and services under clause 7ii77,i74 7iv7 ,exception for extenuating circumstances ,in the case of a prior authorization request submitted to a ,medicare ,advantage plan for an individual enrolled in such plan during a plan year with respect to an item or service identified by the ,secretary pursuant to clause 7ii7 for such plan year1 such plan may1 in lieu of providing a real-time decision with respect to such request in accordance with clause 7i71 delay such decision under extenuating circumstances 7as specified by the ,secretary71 provided that such decision is provided no later than #gb hours after receipt of such request 7or1 in the case that the provider of services or supplier submitting such request has indicated that such delay may seriously jeopardize such individual's life1 health1 or ability to regain maximum function1 no later than #bd hours after receipt of such request74 7v7 ,definition of real-time decision ,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 relating to how quickly a ,medicare ,advantage plan may provide responses with respect to prior authorization requests4 7vi7 ,implementation ,the ,secretary shall use notice and comment rulemaking for each of the following3 7,i7 ,establishing the definition of a real-time decision for purposes of clause 7i74 7,,ii7 ,updating such definition4 7,,iii7 ,initially identifying applicable items or services pursuant to clause 7ii77,i74 7,,iv7 ,updating applicable items and services so identified as described in clause 7ii77,,ii74 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 were subject to a prior authorization requirement under the plan during the previous plan year4 7,,ii7 ,the percentage and number of specified requests 7as defined in subparagraph 7,f77 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 7both in the aggregate and categorized by each item and service74 7,,iii7 ,the percentage and number of specified requests submitted during the previous plan year that were made with respect to an item or service identified by the ,secretary pursuant to paragraph 7#b77;,c77ii7 for such plan year1 and the percentage and number of such requests that were subject to an exception under paragraph 7#b77;,c77iv7 7categorized by each item and service74 7,,iv7 ,the percentage and number of specified requests submitted during the previous plan year that were made with respect to an item or service identified by the ,secretary pursuant to paragraph 7#b77;,c77ii7 for such plan year that were approved 7categorized by each item and service74 7,v7 ,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 appealed4 7,,vi7 ,the number of appeals of specified requests resolved during the preceding plan year1 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 request1 categorized by each applicable item and service and categorized by each level of appeal 7including judicial review74 7,,vii7 ,the percentage and number of specified requests that were denied1 and the percentage and number of specified requests that were approved1 by the plan during the previous plan year through the utilization of decision support technology1 artificial intelligence technology1 machine-learning technology1 clinical decision-making technology1 or any other technology specified by the ,secretary4 7,,viii7 ,the average and the median amount of time 7in hours7 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 service1 excluding any such requests that were not submitted with the medical or other documentation required to be submitted by the plan4 7,,ix7 ,the percentage and number of specified requests that were excluded from the calculation described in subclause 7,,viii7 based on the plan's determination that such requests were not submitted with the medical or other documentation required to be submitted by the plan4 7,x7 ,information on each occurrence during the previous plan year in which1 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 request1 the provider of services or supplier furnishing such item or service determined that a different or additional item or service was medically necessary1 including a specification of whether such plan subsequently approved the furnishing of such different or additional item or service4 7,,xi7 ,a disclosure and description of any technology described in subclause 7,,vii7 that the plan utilized during the previous plan year in making determinations with respect to specified requests4 7,,xii7 ,the number of grievances 7as described in subsection 7f77 received by such plan during the previous plan year that were related to a prior authorization requirement4 7,,xiii7 ,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 that enters into such a contract1 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 request2 and 7,,iii7 to an enrollee of the plan1 upon request1 access to the criteria used by the plan for making determinations with respect to prior authorization requests for an item or service4 7,b7 ,option for plan to provide certain additional information ,as part of the information described in subparagraph 7,a77i7 provided to the ,secretary during a plan year1 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 services4 7,c7 ,regulations ,the ,secretary shall1 through notice and comment rulemaking1 establish requirements for ,medicare ,advantage plans regarding the provision of-- 7i7 access to criteria described in subparagraph 7,a77ii77,,ii7 to providers of services and suppliers in accordance with such subparagraph2 and 7ii7 access to such criteria to enrollees in accordance with subparagraph 7,a77ii77,,iii74 7,d7 ,publication of information ,the ,secretary shall publish information described in subparagraph 7,a77i7 and subparagraph 7,b7 on a public website of the ,centers for ,medicare ,medicaid ,services4 ,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 ,secretary4 7,e7 ,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,f7 ,specified request defined ,for purposes of this paragraph1 the term specified request means a prior authorization request made with respect to an applicable item or service4 7#d7 ,enrollee protection standards ,for purposes of paragraph 7#a77;,a77ii71 the ,secretary shall1 through notice and comment rulemaking1 specify the following enrollee protection standards with respect to the use of prior authorization by ,medicare ,advantage plans for applicable items and services3 7,a7 ,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 plans2 7,b7 ,allowing for the waiver or modification of prior authorization requirements based on the performance of such providers and suppliers in demonstrating compliance with such requirements1 such as adherence to evidence-based medical guidelines and other quality criteria2 and 7,c7 ,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 criteria4 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 ,reports to ,congress 7,a7 ,,gao ,not later than the end of the fourth plan year beginning on or after the date of the enactment of this subsection1 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 plans4 7,b7 ,,hhs ,not later than the end of the fifth plan year beginning 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 a description of the information submitted under paragraph 7#c77;,a77i7 during-- 7i7 in the case of the first such report1 the fourth plan year beginning after the date of the enactment of this subsection2 and 7ii7 in the case of a subsequent report1 the #b plan years preceding the year of the submission of such report4 4 7b7 ,ensuring timely responses for all prior authorization requests submitted under part ,c ,section #aheb7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77 is amended-- 7#a7 in paragraph 7#a77;,a71 by inserting and in accordance with paragraph 7#f7 after paragraph 7#c72 7#b7 in paragraph 7#c77;,b77iii71 by inserting 7or1 subject to subsection 7o71 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 #bjbb1 not later than #bd hours7 after #gb hours4 7#c7 by adding at the end the following new paragraph3 7#f7 ,timeframe for response to prior authorization requests ,subject to paragraph 7#c7 and subsection 7o71 in the case of an organization determination made with respect to a prior authorization request for an item or service to be furnished to an individual submitted on or after the first day of the third plan year beginning after the date of the enactment of this paragraph1 the organization shall notify the enrollee 7and the physician involved1 as appropriate7 of such determination no later than #g days 7or such shorter timeframe as the ,secretary may specify through notice and comment rulemaking1 taking into account enrollee and stakeholder feedback7 after receipt of such request4 4 #c4 ,funding ,the ,secretary of ,health and ,human ,services shall provide for the transfer1 from the ,federal ,hospital ,insurance ,trust ,fund established under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 and the ,federal ,supplementary ,medical ,insurance ,trust ,fund established under section #ahda of such ,act 7#db ,u4,s4,c4 #aciet7 7in such proportion as determined appropriate by the ,secretary7 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account1 of #be1jjj1jjj for fiscal year #bjbb1 to remain available until expended1 for purposes of carrying out the amendments made by this ,act4 ,passed the ,house of ,representatives ,september #ad1 #bjbb4;,cheryl ,l4 ,johnson1,clerk4