,,ib ,union ,cal5d> ,no4 #eab #aag?     
,,congress  #b;d ,session  ,h4 ,r4 #hdhg
 ,report ,no4 #aag-fif1 ,"p ,i ,,9 ,,!  
,,h\se ,,( ,,repres5tatives  ,july #bf1 
#bjbb,ms4 ,del,bene 7= h]self1 ,mr4     
,kelly ( ,p5nsylvania1 ,mr4 ,b]a1 & ,mr4
 ,buc%on7 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$  ,decemb] #cj1 #bjbb,report$ f !
 ,committee on ,ways & ,means ) an      
amendment,strike out all aft] ! enact+  
clause & ins]t ! "p pr9t$ 9 italic      
,decemb] #cj1 #bjbb;,committee on ,en]gy
 & ,comm]ce dis*>g$2 committ$ to !      
,committee ( ! ,:ole ,h\se on ! ,/ate ( 
! ,union & ord]$ to be printed,for text 
( introduc$ bill1 see copy ( bill z     
introduc$ on ,july #bf1 #bjbb  ,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 ( #bjbb4  #b4      
,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$ic>e ,advantage 
plan t imposes any prior au?orization   
requirem5t ) respect to any applicable  
item or s]vice 7z def9$ 9 p>agraph 7#e77
 dur+ a plan ye>1 su* plan %all-- 7,a7  
beg9n+ ) ! ?ird plan ye> beg9n+ aft] !  
date ( ! enactm5t ( ?is subsection-- 7i7
 e/abli% ! electronic prior au?orization
 program describ$ 9 p>agraph 7#b72 &    
7ii7 meet ! enrollee protection /&>ds   
specifi$ pursuant to p>agraph 7#d72 &   
7,b7 beg9n+ ) ! f\r? plan ye> beg9n+    
aft] ! date ( ! enactm5t ( ?is          

subsection1 meet ! transp>5cy           
requirem5ts specifi$ 9 p>agraph 7#c74   
7#b7 ,electronic prior au?orization     
program  7,a7 ,9 g5]al ,= purposes (    
p>agraph 7#a77;,a71 ! electronic prior  
au?orization program describ$ 9 ?is     
p>agraph is a program t provides = !    
secure electronic transmission (-- 7i7 a
 prior au?orization reque/ f a provid] (
 s]vices or suppli] to a ,m$ic>e        
,advantage plan ) respect to an         
applicable item or s]vice to be furni%$ 
to an individual & a response1 9        
accordance ) ?is p>agraph1 f su* plan to
 su* provid] or suppli]2 &  7ii7 any    
heal? claims atta*m5t 7z def9$ =        
purposes ( section #aagc7;a77#b77;,b77  
relat+ to su* reque/ or response4  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 ,an electronic transmission      
describ$ 9 subp>agraph 7,a7 %all comply 
)-- 7,i7 applicable te*nical /&>ds      
adopt$ by ! ,secret>y pursuant to       
section #aagc2 &  7,,ii7 any o!r        
requirem5ts to promote ! /&>dization &  
/reaml9+ ( electronic transactions "u   
?is "p specifi$ by ! ,secret>y4  7iii7  
,deadl9e = specification ( additional   
requirem5ts ,n lat] ?an ,july #a1 #bjbc1
 ! ,secret>y %all f9alize any           
requirem5ts describ$ 9 clause 7ii77,,ii7
 4  7,c7 ,real-"t decisions  7i7 ,9     
g5]al ,subject to clause 7iv71 ! program
 describ$ 9 subp>agraph 7,a7 %all       
provide = real-"t decisions 7z def9$ by 
! ,secret>y 9 accordance ) clause 7v77  
by a ,m$ic>e ,advantage plan ) respect  
to prior au?orization reque/s =         
applicable items & s]vices id5tifi$ by !
 ,secret>y pursuant to clause 7ii7 if   
su* reque/s are submitt$ ) all m$ical or
 o!r docum5tation requir$ by su* plan4  
7ii7 ,id5tification ( items & s]vices   
7,i7 ,9 g5]al ,= purposes ( clause 7i71 

! ,secret>y %all id5tify1 n lat] ?an !  
date on :i* ! initial ann\ncem5t        
describ$ 9 section #ahec7;b77#a77;,b77i7
 = ! ?ird plan ye> beg9n+ aft] ! date ( 
! enactm5t ( ?is subsection is requir$  
to be ann\nc$1 applicable items &       
s]vices = :i* prior au?orization reque/s
 are r\t9ely approv$4  7,,ii7 ,updates  
,! ,secret>y %all consid] updat+ !      
applicable items & s]vices id5tifi$ "u  
subclause 7,i7 bas$ on ! in=mation      
describ$ 9 p>agraph 7#c77;,a77i7 7if    
available & det]m9$ practicable to      
utilize by ! ,secret>y7 & any o!r       
in=mation det]m9$ appropriate by !      
,secret>y n less frequ5tly ?an          
bi5nially4 ,! ,secret>y %all ann\nce any
 su* update t is to apply ) respect to a
 plan ye> 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$4  7iii7 ,reque/ = 
in=mation ,! ,secret>y %all issue a     
reque/ = in=mation = purposes (         
initially id5tify+ applicable items &   

s]vices "u clause 7ii77,i74  7iv7       
,exception = ext5uat+ circum/ances ,9 ! 
case ( a prior au?orization reque/      
submitt$ to a ,m$ic>e ,advantage plan = 
an individual enroll$ 9 su* plan dur+ a 
plan ye> ) respect to an item or s]vice 
id5tifi$ by ! ,secret>y pursuant to     
clause 7ii7 = su* plan ye>1 su* plan    
may1 9 lieu ( provid+ a real-"t decision
 ) respect to su* reque/ 9 accordance ) 
clause 7i71 delay su* decision "u       
ext5uat+ circum/ances 7z specifi$ by !  
,secret>y71 provid$ t su* decision is   
provid$ no lat] ?an #gb h\rs aft]       
receipt ( su* reque/ 7or1 9 ! case t !  
provid] ( s]vices or suppli] submitt+   
su* reque/ has indicat$ t su* delay may 
s]i\sly jeop>dize su* individual's life1
 heal?1 or ability to rega9 maximum     
function1 no lat] ?an #bd h\rs aft]     
receipt ( su* reque/74  7v7 ,def9ition (
 real-"t decision ,9 e/abli%+ !         
def9ition ( a real-"t decision =        
purposes ( clause 7i71 ! ,secret>y %all 
take into acc\nt curr5t m$ical practice1

 te*nology1 heal? c>e indu/ry /&>ds1 &  
o!r relevant in=mation relat+ to h[     
quickly a ,m$ic>e ,advantage plan may   
provide responses ) respect to prior    
au?orization reque/s4  7vi7             
,implem5tation ,! ,secret>y %all use    
notice & comm5t rulemak+ = ea* ( !      
foll[+3 7,i7 ,e/abli%+ ! def9ition ( a  
real-"t decision = purposes ( clause    
7i74  7,,ii7 ,updat+ su* def9ition4     
7,,iii7 ,initially id5tify+ applicable  
items or s]vices pursuant to clause     
7ii77,i74  7,,iv7 ,updat+ applicable    
items & s]vices s id5tifi$ z describ$ 9 
clause 7ii77,,ii74  7#c7 ,transp>5cy    
requirem5ts  7,a7 ,9 g5]al ,= purposes (
 p>agraph 7#a77;,b71 ! transp>5cy       
requirem5ts specifi$ 9 ?is p>agraph are1
 ) respect to a ,m$ic>e ,advantage plan1
 ! foll[+3 7i7 ,! plan1 annually & 9 a  
mann] specifi$ by ! ,secret>y1 %all     
submit to ! ,secret>y ! foll[+          
in=mation3 7,i7 ,a li/ ( all applicable 
items & s]vices t 7 subject to a prior  
au?orization requirem5t "u ! plan dur+ !

 previ\s plan ye>4  7,,ii7 ,! p]c5tage &
 numb] ( specifi$ reque/s 7z def9$ 9    
subp>agraph 7,f77 approv$ dur+ ! previ\s
 plan ye> by ! plan 9 an initial        
det]m9ation & ! p]c5tage & numb] (      
specifi$ reque/s d5i$ dur+ su* plan ye> 
by su* plan 9 an initial det]m9ation    
7bo? 9 ! aggregate & categoriz$ by ea*  
item & s]vice74  7,,iii7 ,! p]c5tage &  
numb] ( specifi$ reque/s submitt$ dur+ !
 previ\s plan ye> t 7 made ) respect to 
an item or s]vice id5tifi$ by !         
,secret>y pursuant to p>agraph          
7#b77;,c77ii7 = su* plan ye>1 & !       
p]c5tage & numb] ( su* reque/s t 7      
subject to an exception "u p>agraph     
7#b77;,c77iv7 7categoriz$ by ea* item & 
s]vice74  7,,iv7 ,! p]c5tage & numb] (  
specifi$ reque/s submitt$ dur+ ! previ\s
 plan ye> t 7 made ) respect to an item 
or s]vice id5tifi$ by ! ,secret>y       
pursuant to p>agraph 7#b77;,c77ii7 = su*
 plan ye> t 7 approv$ 7categoriz$ by ea*
 item & s]vice74  7,v7 ,! p]c5tage &    
numb] ( specifi$ reque/s t 7 d5i$ dur+ !

 previ\s plan ye> by ! plan 9 an initial
 det]m9ation & t 7 subsequ5tly appeal$4 
7,,vi7 ,! numb] ( appeals ( specifi$    
reque/s resolv$ dur+ ! prec$+ plan ye>1 
& ! p]c5tage & numb] ( su* resolv$      
appeals t result$ 9 approval ( ! furni%+
 ( ! item or s]vice t 0 ! subject ( su* 
reque/1 brok5 d[n by ea* applicable item
 & s]vice & brok5 d[n by ea* level (    
appeal 7includ+ judicial review74       
7,,vii7 ,! p]c5tage & numb] ( specifi$  
reque/s t 7 d5i$1 & ! p]c5tage & numb] (
 specifi$ reque/s t 7 approv$1 by ! plan
 dur+ ! previ\s plan ye> ?r\gh !        
utilization ( decision support          
te*nology1 artificial intellig5ce       
te*nology1 ma*9e-le>n+ te*nology1       
cl9ical decision-mak+ te*nology1 or any 
o!r te*nology specifi$ by ! ,secret>y4  
7,,viii7 ,! av]age & ! m$ian am\nt ( "t 
79 h\rs7 t elaps$ dur+ ! previ\s plan   
ye> betwe5 ! submission ( a specifi$    
reque/ to ! plan & a det]m9ation by !   
plan ) respect to su* reque/ = ea* su*  
item & s]vice1 exclud+ any su* reque/s t

 7 n submitt$ ) ! m$ical or o!r         
docum5tation requir$ to be submitt$ by !
 plan4  7,,ix7 ,! p]c5tage & numb] (    
specifi$ reque/s t 7 exclud$ f !        
calculation describ$ 9 subclause        
7,,viii7 bas$ on ! plan's det]m9ation t 
su* reque/s 7 n submitt$ ) ! m$ical or  
o!r docum5tation requir$ to be submitt$ 
by ! plan4  7,x7 ,in=mation on ea*      
occurr5ce dur+ ! previ\s plan ye> 9 :i*1
 dur+ a surgical or m$ical proc$ure     
involv+ ! furni%+ ( an applicable item  
or s]vice ) respect to :i* su* plan _h  
approv$ a prior au?orization reque/1 !  
provid] ( s]vices or suppli] furni%+ su*
 item or s]vice det]m9$ t a diff]5t or  
additional item or s]vice 0 m$ically    
necess>y1 includ+ a specification ( :e!r
 su* plan subsequ5tly approv$ ! furni%+ 
( su* diff]5t or additional item or     
s]vice4  7,,xi7 ,a disclosure &         
description ( any te*nology describ$ 9  
subclause 7,,vii7 t ! plan utiliz$ dur+ 
! previ\s plan ye> 9 mak+ det]m9ations )
 respect to specifi$ reque/s4  7,,xii7  

,! numb] ( grievances 7z describ$ 9     
subsection 7f77 receiv$ by su* plan dur+
 ! previ\s plan ye> t 7 relat$ to a     
prior au?orization requirem5t4  7,,xiii7
 ,su* o!r in=mation z ! ,secret>y       
det]m9es appropriate4  7ii7 ,! plan %all
 provide-- 7,i7 to ea* provid] or       
suppli] :o seeks to ent] into a contract
 ) su* plan to furni% applicable items &
 s]vices "u su* 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* su*
 provid] & suppli] t ent]s into su* a   
contract1 access to ! crit]ia us$ by !  
plan = mak+ su* det]m9ations & an       
itemization ( ! m$ical or o!r           
docum5tation requir$ to be submitt$ by a
 provid] or suppli] ) respect to su* a  
reque/2 &  7,,iii7 to an enrollee ( !   
plan ^u reque/1 access to ! crit]ia us$ 
by ! plan = mak+ det]m9ations ) respect 
to prior au?orization reque/s = an item 
or s]vice4  7,b7 ,option = plan to      

provide c]ta9 additional in=mation ,z "p
 ( ! in=mation describ$ 9 subp>agraph   
7,a77i7 provid$ to ! ,secret>y dur+ a   
plan ye>1 a ,m$ic>e ,advantage plan may 
elect to include in=mation reg>d+ !     
p]c5tage & numb] ( specifi$ reque/s made
 ) respect to an individual & an item or
 s]vice t 7 d5i$ by ! plan dur+ ! prec$+
 plan ye> 9 an initial det]m9ation bas$ 
on su* reque/s fail+ to demon/rate t su*
 individuals met ! cl9ical crit]ia      
e/abli%$ by su* plan to receive su*     
items or s]vices4  7,c7 ,regulations ,! 
,secret>y %all1 ?r\gh notice & comm5t   
rulemak+1 e/abli% requirem5ts = ,m$ic>e 
,advantage plans reg>d+ ! provision (-- 
7i7 access to crit]ia describ$ 9        
subp>agraph 7,a77ii77,,ii7 to provid]s (
 s]vices & suppli]s 9 accordance ) su*  
subp>agraph2 &  7ii7 access to su*      
crit]ia to enrollees 9 accordance )     
subp>agraph 7,a77ii77,,iii74  7,d7      
,publication ( in=mation ,! ,secret>y   
%all publi% all in=mation describ$ 9    
subp>agraph 7,a77i7 & subp>agraph 7,b7  

on a public website ( ! ,c5t]s = ,m$ic>e
  ,m$icaid ,s]vices4 ,su* in=mation %all
 be s publi%$ on an individual plan     
level & may 9 addition be aggregat$ 9   
su* mann] z det]m9$ appropriate by !    
,secret>y4  7,e7 ,med,pac report ,n lat]
 ?an #c ye>s aft] ! date in=mation is   
fir/ submitt$ "u subp>agraph 7,a77i71 ! 
,m$ic>e ,paym5t ,advisory ,commission   
%all submit to ,congress a report on su*
 in=mation t includes a descriptive     
analysis ( ! use ( prior au?orization4  
,z appropriate1 ! ,commission %\ld      
report on /ati/ics includ+ ! frequ5cy ( 
appeals & ov]turn$ decisions4 ,!        
,commission %all provide recomm5dations1
 z appropriate1 on any improvem5t t %\ld
 be made to ! electronic prior          
au?orization programs ( ,m$ic>e         
,advantage plans4  7,f7 ,specifi$ reque/
 def9$ ,= purposes ( ?is p>agraph1 ! t]m
 specifi$ reque/ means a prior          
au?orization reque/ made ) respect to an
 applicable item or s]vice4  7#d7       
,enrollee protection /&>ds ,! ,secret>y 

( ,heal? & ,human ,s]vices %all1 ?r\gh  
notice & comm5t rulemak+1 specify       
requirem5ts ) respect to ! use ( prior  
au?orization by ,m$ic>e ,advantage plans
 = applicable items & s]vices to        
ensure-- 7,a7 t su* plans adopt         
transp>5t prior au?orization programs   
develop$ 9 consultation ) enrollees & ) 
provid]s & suppli]s ) contracts 9 effect
 ) su* plans = furni%+ su* items &      
s]vices "u su* plans2  7,b7 t su*       
programs all[ = ! waiv] or modification 
( prior au?orization requirem5ts bas$ on
 ! p]=mance ( su* provid]s & suppli]s 9 
demon/rat+ compliance ) su* requirem5ts1
 su* z adh]5ce to evid5ce-bas$ m$ical   
guidel9es & o!r quality crit]ia2 &  7,c7
 t su* plans conduct annual reviews (   
su* items & s]vices = :i* prior         
au?orization requirem5ts are impos$ "u  
su* plans ?r\gh a process t takes into  
acc\nt input f enrollees & f provid]s & 
suppli]s ) su* contracts 9 effect & is  
bas$ on consid]ation ( prior            
au?orization data f previ\s plan ye>s & 

analyses ( curr5t cov]age crit]ia4  7#e7
 ,applicable item or s]vice ,= purposes 
( ?is subsection1 ! t]m applicable item 
or s]vice means1 ) respect to a ,m$ic>e 
,advantage plan1 any item or s]vice =   
:i* b5efits are available "u su* plan1  
o!r ?an a cov]$ "p ,d drug4  7#f7       
,reports to ,congress  7,a7 ,,gao ,n    
lat] ?an ! end ( ! f\r? plan ye> beg9n+ 
on or aft] ! date ( ! enactm5t ( ?is    
subsection1 ! ,comptroll] ,g5]al ( !    
,unit$ ,/ates %all submit to ,congress a
 report conta9+ an evaluation ( !       
implem5tation ( ! requirem5ts ( ?is     
subsection & an analysis ( issues 9     
implem5t+ su* requirem5ts fac$ by       
,m$ic>e ,advantage plans4  7,b7 ,,hhs ,n
 lat] ?an ! end ( ! fif? plan ye> beg9n+
 aft] ! date ( ! enactm5t ( ?is         
subsection1 & bi5nially !reaft] ?r\gh ! 
date t is #aj ye>s aft] su* date (      
enactm5t1 ! ,secret>y %all submit to    
,congress a report conta9+ a description
 ( ! in=mation submitt$ "u p>agraph     
7#c77;,a77i7 dur+-- 7i7 9 ! case ( !    

fir/ su* report1 ! f\r? plan ye> beg9n+ 
aft] ! date ( ! enactm5t ( ?is          
subsection2 &  7ii7 9 ! case ( a        
subsequ5t report1 ! #b plan ye>s prec$+ 
! ye> ( ! submission ( su* report4  4   
7b7 ,ensur+ timely responses = all prior
 au?orization reque/s submitt$ "u "p ,c 
,section #aheb7;g7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77 is 
am5d$-- 7#a7 9 p>agraph 7#a77;,a71 by   
ins]t+ & 9 accordance ) p>agraph 7#f7   
aft] p>agraph 7#c72  7#b7 9 p>agraph    
7#c77;,b77iii71 by ins]t+ 7or1 ) respect
 to prior au?orization reque/s submitt$ 
on or aft] ! fir/ day ( ! ?ird plan ye> 
beg9n+ aft] ! date ( ! enactm5t ( !     
,improv+ ,s5iors' ,timely ,access to    
,c>e ,act ( #bjbb1 n lat] ?an #bd h\rs7 
aft] #gb h\rs4  7#c7 by add+ at ! end ! 
foll[+ new p>agraph3  7#f7 ,timeframe = 
response to prior au?orization reque/s  
,subject to p>agraph 7#c7 & subsection  
7o71 9 ! case ( an organization         
det]m9ation made ) respect to a prior   
au?orization reque/ = an item or s]vice 

to be furni%$ to an individual submitt$ 
on or aft] ! fir/ day ( ! ?ird plan ye> 
beg9n+ aft] ! date ( ! enactm5t ( ?is   
p>agraph1 su* det]m9ation %all be made  
no lat] ?an #g days 7or su* %ort]       
timeframe z ! ,secret>y may specify     
?r\gh notice & comm5t rulemak+1 tak+    
into acc\nt enrollee & /akehold]        
fe$back7 aft] receipt ( su* reque/4  4  
7c7 ,fund+ ,! ,secret>y ( ,heal? &      
,human ,s]vices %all provide = !        
transf]1 f ! ,f$]al ,hospital ,insurance
 ,tru/ ,fund e/abli%$ "u section #ahag (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acie;i7 & ! ,f$]al ,supplem5t>y       
,m$ical ,insurance ,tru/ ,fund e/abli%$ 
"u section #ahda ( su* ,act 7#db        
,u4,s4,c4 #aciet7 79 su* proportion z   
det]m9$ appropriate by ! ,secret>y7 to !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices    
,program ,managem5t ,acc\nt1 (          
#ae1jjj1jjj = fiscal ye> #bjbb1 to rema9
 available until exp5d$1 = purposes (   
c>ry+ out ! am5dm5ts made by ?is ,act4  
,decemb] #cj1 #bjbb,report$ f !         

,committee on ,ways & ,means ) an       
amendment,december #cj1 #bjbb;,committee
 on ,en]gy & ,comm]ce dis*>g$2 committ$ 
to ! ,committee ( ! ,:ole ,h\se on !    
,/ate ( ! ,union & ord]$ to be pr9t$