,,ii  #aah? ,,congress  #b;d ,session   
,s4 #deah  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,june #ab1 #bjbd,mr4   
,m>%all 7= himself1 ,ms4 ,s9ema1 ,mr4   
,?une1 ,mr4 ,br[n1 ,ms4 ,cortez ,ma/o1  
,ms4 ,coll9s1 & ,mrs4 ,fis*]7 introduc$ 
! foll[+ bill2 :i* 0 read twice & ref]r$
 to ! ,committee on ,f9ance  ,a ,,bill  
,to am5d title ,,xviii ( ! ,social      
,security ,act to e/abli% requirem5ts ) 
respect to ! use ( prior au?orization "u
 ,m$ic>e ,advantage plans4  #a4 ,%ort   
title ,?is ,act may be cit$ z ! ,improv+
 ,s5iors' ,timely ,access to ,c>e ,act (
 #bjbd4  #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+ ) plan ye>s 
beg9n+ on or aft] ,janu>y #a1 #bjbg--   
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+ ) plan    
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbf1 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    
support+ docum5tation 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 )          
applicable te*nical /&>ds & o!r         
requirem5ts to promote ! /&>dization &  
/reaml9+ ( electronic transactions      
adopt$ by ! ,secret>y4  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 t 7 d5i$ dur+ !
 previ\s plan ye> by ! plan 9 an initial
 det]m9ation & t 7 subsequ5tly appeal$4 
7,,iv7 ,! numb] ( appeals ( specifi$    
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 categoriz$ by ea* applicable    
item & s]vice & categoriz$ by ea* level 
( appeal 7includ+ judicial review74     
7,v7 ,! 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,,vi7 ,! 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,,vii7 ,! 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,,viii7 ,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,,ix7 ,a disclosure & description ( any
 te*nology describ$ 9 subclause 7,v7 t !
 plan utiliz$ dur+ ! previ\s plan ye> 9 
mak+ det]m9ations ) respect to specifi$ 
reque/s4  7,x7 ,! 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,,xi7 ,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 ( !   
plan1 ^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% 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 ,= purposes (
 p>agraph 7#a77;,a77ii71 ) respect to ! 
use ( prior au?orization by ,m$ic>e     
,advantage plans = applicable items &   
s]vices1 ! enrollee protection /&>ds    
specifi$ 9 ?is p>agraph are-- 7,a7 !    
adoption ( 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
 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
 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 def9$ ,=    
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 ,janu>y #a1      
#bjbh1 ! ,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  7i7 ,! ,secret>y ,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+-- 7,i7 9 ! case ( !   
fir/ su* report1 ! f\r? plan ye> beg9n+ 
aft] ! date ( ! enactm5t ( ?is          
subsection2 &  7,,ii7 9 ! case ( a      
subsequ5t report1 ! #b plan ye>s prec$+ 
! ye> ( ! submission ( su* report4  7ii7
 ,,cms ,n lat] ?an ,janu>y #a1 #bjbg1 ! 
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices & ! 
,(fice ( ,national ,coord9ator = ,heal? 
,in=mation ,te*nology %all submit to    
,congress & publi% on ! int]net website 
( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices 
a report t-- 7,i7 def9es ! t]m real-"t  
decision & details h[ ! def9ition = su* 
t]m may be updat$ bas$ on any           
te*nological advances2  7,,ii7 us+ !    
data submitt$ to ! ,secret>y "u p>agraph
 7#c77;,a77i71 details a process =      
real-"t decisions = items & s]vices =   
r\t9ely approv$ s]vices = purposes ( !  

electronic prior au?orization program   
describ$ 9 p>agraph 7#b72 &  7,,iii7    
includes an analysis (-- 7aa7 items &   
s]vices t are r\t9ely approv$2  7bb7    
items & s]vices id5tifi$ 9 item 7aa7 t  
c\ld be eligible = real-"t decisions2   
7cc7 h[ e/abli%+ real-"t decisions = su*
 items & s]vices c\ld-- 7,,aa7 improve  
enrollee access to b5efits "u ?is "p2   
7,,bb7 produce op]ational effici5cies = 
provid]s ( s]vices & suppli]s & ,m$ic>e 
,advantage plans2 & 7,,cc7 r$uce heal?  
disp>ities = ,m$ic>e ,advantage         
enrollees 9 rural & l[-income           
communities2 &  7dd7 h[ ! use ( automat$
 decision mak+ & artificial intellig5ce 
by ,m$ic>e ,advantage plans impact      
pati5t access1 includ+ disp>ities 9     
access = rural & l[-income b5efici>ies1 
to r\t9ely approv$ items & s]vices4  4  
7b7 ,provid+ ! ,secret>y au?ority ,to   
en=ce 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$-- 7#a7 9 p>agraph 7#a77;,a71 by   
ins]t+ & 9 accordance ) any timeframe   
e/abli%$ by ! ,secret>y "u p>agraph 7#f7
 aft] p>agraph 7#c72  7#b7 9 p>agraph   
7#c77;,b77iii71 by ins]t+ 7or1 subject  
to subsection 7o71 ) 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 ( 
#bjbd1 any timeframe e/abli%$ by !      
,secret>y "u p>agraph 7#f77 aft] #gb    
h\rs2 &  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 ! ,secret>y may e/abli%1 = purposes
 ( an organization det]m9ation made )   
respect to a prior au?orization reque/ =
 an item or s]vice to be furni%$ to an  
individual1 timeframes1 su* z #bd h\rs1 
= ! organization to notify ! enrollee 7&
 ! physician involv$1 z appropriate7 (  
su* det]m9ation =-- 7,a7 a reque/ =     
exp$it$ det]m9ation describ$ 9 p>agraph 

7#c77;,a72  7,b7 a real "t decision =   
r\t9ely approv$ items & s]vices2 &  7,c7
 any o!r prior au?orization reque/4  4