,i  #aag? ,,congress  #b;d ,session  ,h4
 ,r4 #giie  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,june #i1 #bjbb,mr4   
,burgess 7= himself1 ,mr4 ,vic5te       
,gonzalez ( ,texas1 & ,mr4 ,jackson7    
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 exempt        
qualify+ physicians f prior au?orization
 requirem5ts "u ,m$ic>e ,advantage      
plans1 & = o!r purposes4  #a4 ,%ort     
title ,?is ,act may be cit$ z ! ,gett+  
,ov] ,l5g?y ,delays 9 ,c>e ,z ,requir$  
by ,doctors ,act ( #bjbb or ! ,,gold    
,,c>d ,act ( #bjbb4  #b4 ,exemption =   
qualify+ physicians f prior au?orization
 requirem5ts "u ,,ma 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 ,exemption = qualify+  
physicians f prior au?orization         
requirem5ts  7#a7 ,9 g5]al  7,a7        
,exemption  7i7 ,9 g5]al ,9 ! case ( an 
,,ma organization :i* utilizes a prior  
au?orization process 7z def9$ 9         
subp>agraph 7,b77 ) respect to a plan   
ye> 7beg9n+ ) ! second plan ye> beg9n+  
aft] ! date ( ! enactm5t ( ?is          
subsection71 subject to ! succe$+       
provisions ( ?is subsection1 a physician
 %all be exempt f ! prior au?orization  
requirem5ts "u su* process = ! p]iod (  
su* plan ye> ) respect to a specific    
item1 s]vice1 or gr\p ( simil> s]vices1 
if dur+ ! prec$+ plan ye> at lea/ #ij   
p]c5t ( prior au?orization reque/s      
submitt$ to su* organization by su*     
physician = su* item1 s]vice1 or gr\p 7 
approv$ by su* organization 7includ+ any
 approval grant$ aft] an appeal74 ,su*  
exemption %all cont9ue to apply )       
respect to su* physician furni%+ su*    
item1 s]vice1 or gr\p ( simil> s]vices 9

 subsequ5t plan ye>s until ! e>li] (--  
7,i7 ! date on :i* su* exemption is     
revok$ "u p>agraph 7#e72 or  7,,ii7 !   
date on :i* su* physician opts out ( su*
 exemption "u p>agraph 7#c77;,c74  7ii7 
,special rules ,= purposes ( det]m9+    
:e!r a physician qualifies = an         
exemption "u clause 7i7 = a plan ye> =  
an item1 s]vice1 or gr\p ( s]vices1 9   
calculat+ :e!r at lea/ #ij p]c5t ( prior
 au?orization reque/s submitt$ by su*   
physician = su* item1 s]vices1 or gr\p  
dur+ ! prec$+ plan ye> 7 approv$1 an    
,,ma organization %all-- 7,i7 subject to
 subclause 7,,ii71 treat any su* claim t
 0 initially d5i$1 subsequ5tly appeal$1 
& t rema9s p5d+ appeal at ! "t ( su*    
calculation z hav+ be5 approv$ if m ?an 
#cj days h elaps$ s9ce ! date su* appeal
 0 fil$2 &  7,,ii7 9 ! case t1 dur+ su* 
plan ye>1 su* organization *ang$ any    
t]ms ( cov]age = su* item1 s]vice1 or   
gr\p ( s]vices1 n take into acc\nt any  
claims = su* item1 s]vice1 or gr\p (    
s]vices t 7 submitt$ dur+ ! #ij-;day    

p]iod beg9n+ on ! date ( su* *ange4     
7,b7 ,prior au?orization process ,=     
purposes ( ?is subsection1 ! t]m prior  
au?orization process means1 ) respect to
 cov]age & paym5t = items & s]vices 7o!r
 ?an a cov]$ "p ,d drug7 "u an ,,ma plan
 (f]$ by an ,,ma organization = a plan  
ye>1 a process "u :i* su* organization  
7or a contractor ( su* organization7    
det]m9es ! m$ical necessity or m$ical   
appropriat5ess ( su* items & s]vices    
prior to ! furni%+ ( su* items & s]vices
 or t o!rwise requires an individual    
enroll$ "u su* plan1 or a provid] (     
s]vices or suppli] s*$ul$ to furni%     
items & s]vices to su* individual1 to   
notify su* plan 7or su* contractor7     
prior to su* individual receiv+ su*     
items & s]vices4  7#b7 ,frequ5cy (      
det]m9ation ( eligibility = exemption   
,an ,,ma organization may n evaluate a  
physician = ! exemption describ$ 9      
p>agraph 7#a7 m ?an once dur+ any plan  
ye>4  7#c7 ,notification requirem5ts    
7,a7 ,qualification ,an ,,ma            

organization %all1 n lat] ?an #cj days  
be=e ! fir/ day ( ea* plan ye>1 notify  
ea* physician :o qualifies = ! exemption
 describ$ 9 p>agraph 7#a7 ( su*         
qualification & ! items1 s]vices1 or    
gr\p ( simil> s]vices ) respect to :i*  
su* exemption applies = su* physician4  
,no?+ 9 ?is subp>agraph %all preclude an
 ,,ma organization f notify+ a physician
 ( su* exemption at additional times    
?r\gh\t a plan ye>4  7,b7 ,reque/s "u   
exemption ,9 ! case ( a physician       
describ$ 9 subp>agraph 7,a7 :o submits a
 prior au?orization reque/ to an ,,ma   
organization = an item or s]vice )      
respect to :i* an exemption applies "u  
?is subsection1 su* organization %all   
notify su* physician ( su* exemption z  
soon z possible 7b 9 no case lat] ?an   
#bd h\rs aft] receiv+ su* reque/74  7,c7
 ,opt out ,any physician eligible = an  
exemption "u p>agraph 7#a7 may          
volunt>ily waive su* exemption by       
provid+ writt5 notice to ! applicable   
,,ma organization4  7#d7 ,requirem5t =  

cov]age & paym5t ,9 ! case ( a physician
 :o qualifies = ! exemption describ$ 9  
p>agraph 7#a7 ) respect to an item1     
s]vice1 or gr\p ( simil> s]vices1 an    
,,ma organization may n d5y or r$uce    
cov]age & paym5t = su* an item1 s]vice1 
or gr\p bas$ on m$ical necessity or     
appropriat5ess ( c>e4  7#e7 ,protections
 p]ta9+ to revocation ( gold c>d  7,a7  
,9 g5]al ,an ,,ma organization may      
revoke an exemption describ$ 9 p>agraph 
7#a7 grant$ ) respect to a physician =  
an item1 s]vice1 or gr\p ( simil>       
s]vices = a plan ye> only if-- 7i7 !    
,,ma organization-- 7,i7 det]m9es t--   
7aa7 less ?an #ij p]c5t ( claims        
submitt$ by su* physician = su* item1   
s]vice1 or gr\p dur+ ! #ij-;day p]iod   
end+ on ! date ( su* revocation w\ld h  
be5 approv$ "u ! prior au?orization     
process employ$ by su* plan _h su*      
process appli$ ) respect to su* claims2 
or  7bb7 9 ! case t few] ?an #aj claims 
7 submitt$ by su* physician = su* item1 
s]vice1 or gr\p dur+ ! #ij-;day p]iod   

end+ on ! date ( su* revocation1 less   
?an #ij p]c5t ( ! la/ #aj claims        
submitt$ by su* physician = su* item1   
s]vice1 or gr\p z ( ! date ( su*        
revocation w\ld h be5 s approv$2  7,,ii7
 furni%es su* physician ) a notice ( su*
 revocation conta9+ ! claim in=mation   
7includ+ id5tification ( specific items 
& s]vices & ! individual to :om su*     
items & s]vices 7 furni%$7 on :i* !     
det]m9ation "u subclause 7,i7 0 made2 & 
7,,iii7 includes 9 su* notice a         
pla9-language description ( h[ su*      
physician may appeal su* det]m9ation 9  
accordance ) ! rules promulgat$ "u      
subp>agraph 7,b72 &  7ii7 ! individual  
conduct+ ! det]m9ation "u clause        
7ii77,i7-- 7,i7 is a physician2  7,,ii7 
possesses a curr5t & nonre/rict$ lic5se 
to practice m$ic9e 9 ! ,/ate 9 :i* !    
items1 s]vices1 or gr\p ( s]vices to :i*
 su* exemption applies 7 furni%$2       
7,,iii7 is actively engag$ 9 ! practice 
( m$ic9e 9 ! same or simil> specialty z 
a physician t w\ld typically furni% su* 

item1 s]vice1 or gr\p ( s]vices2 &      
7,,iv7 is kn[l$geable ab\t ! furni%+ (1 
& has exp]i5ce furni%+1 su* item1       
s]vice1 or gr\p ( s]vices4  7,b7 ,appeal
 ( exemption ,! ,secret>y %all1 ?r\gh   
notice & comm5t rulemak+1 e/abli% a     
process "u :i* a physician may appeal a 
revocation "u subp>agraph 7,a74 ,su*    
process %all ensure t any su* appeal is 
resolv$ )9 #cj days ( su* appeal be+    
submitt$ "u su* process4  7,c7 ,treatm5t
 ( unresolv$ claims ,! provisions (     
p>agraph 7#a77;,a77ii7 %all apply )     
respect to ! treatm5t ( claims = a      
det]m9ation made "u subp>agraph 7,a7 9 !
 same mann] z su* provisions apply )    
respect to ! treatm5t ( claims = a      
det]m9ation made "u p>agraph 7#a77;,a74 
4  7b7 ,rulemak+ ,! ,secret>y ( ,heal? &
 ,human ,s]vices %all1 ?r\gh rulemak+1  
specify requirem5ts ) respect to ! use (
 prior au?orization by ,m$ic>e          
,advantage plans = items & s]vices      
describ$ 9 subsection 7o77#a7 ( section 
#aheb ( ! ,social ,security ,act 7#db   

,u4,s4,c4 #aciew-#bb71 z add$ by        
subsection 7a71 to ensure 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* plans4  7c7 ,report  
,n lat] ?an #b ye>s aft] ! date ( !     
enactm5t ( ?is ,act1 ! ,secret>y (      
,heal? & ,human ,s]vices %all submit to 
,congress a report on ! pot5tial impacts
 ( ! am5dm5t made by ?is section on     
communities at high risk = heal?        
disp>ities4  #c4 ,opportunity = provid]s
 to pres5t cases = cov]age & paym5t dur+
 ! prior au?orization process "u ,,ma   
plans ,section #aheb ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciew-#bb71 z am5d$ by section #b1 is  
fur!r am5d$ by add+ at ! end ! foll[+   
new subsection3  7p7 ,opportunity =     
provid]s ,to pres5t cases = cov]age &   
paym5t dur+ ! prior au?orization process
  7#a7 ,9 g5]al ,= plan ye>s beg9n+ ) ! 
second plan ye> beg9n+ aft] ! date ( !  

enactm5t ( ?is subsection1 any prior    
au?orization process 7z def9$ 9         
subsection 7o77#a77;,b77 ) respect to ! 
cov]age & paym5t = items & s]vices 7o!r 
?an a cov]$ "p ,d drug7 "u an ,,ma plan 
(f]$ by an ,,ma organization %all       
provide1 prior to any cov]age or paym5t 
det]m9ation ) respect to an item or     
s]vice subject to su* process1 = an     
opportunity = a provid] ( s]vices or    
suppli] seek+ prior au?orization to     
furni% su* item or s]vice to discuss ) a
 qualify+ physician 7z def9$ 9 p>agraph 
7#b77-- 7,a7 ! treatm5t plan = !        
individual :o w\ld be furni%$ su* item  
or s]vice2 &  7,b7 ! cl9ical basis on   
:i* ! organization w det]m9e cov]age or 
paym5t = su* item or s]vice4  7#b7      
,qualify+ physician def9$ ,= purposes ( 
p>agraph 7#a71 ! t]m qualify+ physician 
means1 ) respect to an item or s]vice   
subject to a process describ$ 9 su*     
p>agraph t a provid] ( s]vices or       
suppli] is seek+ to furni% to an        
individual1 a physician t-- 7,a7        

possesses a curr5t & nonre/rict$ lic5se 
to practice m$ic9e 9 ! ,/ate 9 :i* su*  
item or s]vice is to be furni%$2  7,b7  
is actively engag$ 9 ! practice ( m$ic9e
 9 ! same or simil> specialty z a       
provid] ( s]vices or suppli] t w\ld     
typically furni% su* item or s]vice2 &  
7,c7 is kn[l$geable ab\t ! furni%+ (1 & 
has exp]i5ce furni%+1 su* item or       
s]vice4  4