,,ii #aaith ,,congress #b;d ,session ,s4 #dchd ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,april #bg1 #bjbf,mr4 ,marshall 7for himself and ,mr4 ,whitehouse7 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 provide for certain reforms under the ,medicare ,advantage program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,medicare ,advantage ,improvement ,act of #bjbf4 #b4 ,improving access to timely care for enrollees of ,medicare ,advantage plans 7a7 ,reducing timeframes for ,medicare ,advantage organizations ,to respond to certain authorization requests 7#a7 ,standard organization determinations ,section #aheb7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#a77 is amended-- 7,a7 in subparagraph 7,a71 in the second sentence1 by inserting subparagraph 7,c7 and after ,subject to2 7,b7 in subparagraph 7,b71 by striking ,such a determination and inserting ,a determination described in subparagraph 7,a7 or 7,c72 and 7,c7 by adding at the end the following new subparagraph3 7,c7 ,required timeframes for responses to certain authorization requests 7i7 ,in general ,subject to clause 7ii7 and paragraph 7#c77;,b77iii71 the procedure established pursuant to subparagraph 7,a7 by a ,medicare ,advantage organization offering an ,,ma plan shall provide that in the case of a request made on or after ,january #a1 #bjbh1 for a specified authorization 7as defined in clause 7iii77 with respect to an individual enrolled under such plan1 the ,medicare ,advantage organization must notify the individual 7and the provider of services or supplier involved1 as appropriate7 of the determination regarding such request as expeditiously as the health condition of the individual requires1 but1 subject to clause 7iv71 not later than #gb hours after receipt of the request4 7ii7 ,extensions ,subject to clause 7iv71 a ,medicare ,advantage organization offering an ,,ma plan may extend the deadline applied under clause 7i7 or the deadline applied under paragraph 7#c77;,b77iii77,,ii71 as applicable1 with respect to a determination regarding a specified request for an individual enrolled under the ,,ma plan1 by up to #g calendar days if-- 7,i7 the individual requests the extension2 7,,ii7 the extension is needed for purposes of obtaining additional relevant medical evidence from a provider of services or supplier that does not have a contract with the ,,ma organization to furnish items and services to individuals enrolled under the ,,ma plan2 or 7,,iii7 the extension is in the individual's interest and is justified by reason of extraordinary1 exigent1 or other nonroutine circumstances that are not within the reasonable control of the ,,ma organization 7as determined by the ,secretary74 7iii7 ,specified authorization defined ,for purposes of this part1 the term specified authorization-- 7,i7 means1 with respect to an individual enrolled under an ,,ma plan offered by a ,medicare ,advantage organization1 an authorization of coverage or payment for an item or service through-- 7aa7 a prior authorization or preservice determination of coverage or payment2 or 7bb7 a concurrent determination made while the individual is receiving the relevant item or service2 and 7,,ii7 includes an authorization for a transfer of the individual between hospitals or between a hospital and post-acute care facility4 7iv7 ,secretarial authority ,with respect to requests for a specified authorization made on or after ,january #a1 #bjcj1 in carrying out clause 7i7 and 7ii7 and paragraph 7#c77;,b77iii77,,ii71 the ,secretary may specify through notice and comment rulemaking a deadline other than the deadline specified in the relevant clause or paragraph4 4 7#b7 ,expedited organization determinations ,section #aheb7;g77#c77;,b77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#c77;,b77iii77 is amended-- 7,a7 by striking ,timely response4--,in cases described and inserting3 ,timely response4-- 7,i7 ,in general ,subject to subclause 7,,ii71 in cases described 2 and 7,b7 by adding at the end the following new subclause3 7,,ii7 ,reducing expedited timeframes for responses to certain authorization requests ,subject to paragraph 7#a77;,c77ii71 in cases described in clauses 7i7 and 7ii7 that are related to an expedited determination for a specified authorization 7as defined in paragraph 7#a77;,c77iii77 for which a request is submitted on or after ,january #a1 #bjbh1 the ,medicare ,advantage organization shall notify the enrollee 7and the physician involved1 as appropriate7 of the determination under time limitations established by the ,secretary4 ,subject to paragraph 7#a77;,c77iv71 such notification shall be made not later than #bd hours after the receipt of the request for the determination 7or receipt of the information necessary to make the determination74 4 7#c7 ,improved transparency of certain prior authorization information on the ,,ma plan level ,beginning with plan years beginning on or after ,january #a1 #bjbh1 in carrying out the provisions of section #dbb4abb7;c7 of title #db1 ,code of ,federal ,regulations 7or any successor regulation71 the ,secretary of ,health and ,human ,services shall-- 7,a7 require ,medicare ,advantage organizations to report prior authorization data described in such section on the plan level and on the ,medicare ,advantage organization parent level in addition to the contract level2 7,b7 require ,medicare ,advantage organizations to report prior authorization data described in such section in a manner that allows comparison of such data based on provider and service category2 and 7,c7 in addition to making such data publicly available1 as described in such section1 make such data available in a downloadable format that is accessible for research purposes and oversight and enforcement activities of the ,secretary4 7b7 ,real-,time authorization decisions for certain identified services ,section #aheb7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#a771 as amended by subsection 7a71 is further amended-- 7#a7 in subparagraph 7,a71 in the second sentence1 by striking subparagraph 7,c7 and and inserting subparagraphs 7,c7 and 7,d7 and2 7#b7 in subparagraph 7,b71 by striking ,a determination described in subparagraph 7,a7 or 7,c7 and inserting ,a determination described in subparagraph 7,a71 7,c71 or 7,d72 7#c7 in subparagraph 7,c77i71 by striking ,subject to clause 7ii7 and inserting ,subject to clause 7ii71 subparagraph 7,d712 and 7#d7 by adding at the end the following new subparagraph3 7,d7 ,real-time authorization decisions for identified services 7i7 ,in general ,the procedure established pursuant to subparagraph 7,a7 shall require that the ,medicare ,advantage organization has in place a mechanism and process through which1 beginning ,january #a1 #bjbh1 the organization provides a real-time determination1 in accordance with this subparagraph1 in response to any request for a specified authorization 7as defined in subparagraph 7,c77iii77 that is-- 7,i7 made with respect to an item or service identified on the most recent list published pursuant to clause 7iii72 and 7,,ii7 submitted through certified ,,ehr technology 7as defined in section #ahdh7o77#d774 7ii7 ,requirements for real-time mechanism and process ,the mechanism and process required under clause 7i7 shall-- 7,i7 include real-time tools capable of providing immediate automated approvals2 7,,ii7 provide for the integration of such tools in a manner that is interoperable with certified ,,ehr technology 7as so defined7 used by providers of services and suppliers2 and 7,,iii7 enable immediate notification to the provider of services or supplier1 as applicable1 of determinations1 including1 in the case of a denial1 notification of any additional documentation needed4 7iii7 ,annual publication of list of identified services requiring real-time authorization support ,for purposes of this subparagraph1 for each plan year beginning on or after ,january #a1 #bjbh1 the ,secretary shall annually establish through notice and comment rulemaking a list identifying the following items and services3 7,i7 ,items and services for which1 with respect to the previous plan year1 at least #ij percent of requests for a specified authorization were approved across all ,medicare ,advantage organizations4 7,,ii7 ,items and services that are clinically low-risk and routine1 as defined by the ,secretary through notice and comment rulemaking4 7,,iii7 ,items and services that the ,secretary identifies1 according to standards specified by the ,secretary through notice and comment rulemaking1 as representative of significant service volume and administrative burden for acquiring such a specified authorization4 7iv7 ,improving transparency 7,i7 ,quarterly ,,mao reports to ,,cms ,beginning ,january #a1 #bjbh1 and quarterly thereafter1 each ,medicare ,advantage organization offering an ,,ma plan shall submit to the ,secretary 7in a form and manner specified by the ,secretary7 information 7presented by provider and service type7 regarding real-time determinations made by the organization during the previous quarter pursuant to this subparagraph1 including information on-- 7aa7 the number of real-time determinations made during the quarter1 and the percentage of all determinations made during the quarter with respect to an item or service identified on the most recent list published pursuant to clause 7iii7 that were real-time determinations2 7bb7 the number and percentage of real-time determinations made during such quarter that were approved2 7cc7 the number and percentage of such determinations that were denied2 7dd7 the number and percentage of such denied determinations that were appealed2 7ee7 the number and percentage of such appealed determinations that were overturned2 and 7ff7 the number and percentage of provider complaints regarding the mechanism and process implemented by the ,medicare ,advantage organization pursuant to this subparagraph4 ,the information submitted pursuant to the previous sentence shall include such information and be provided in such a manner to enable comparison and analysis of such information on the ,medicare ,advantage organization level1 ,medicare ,advantage parent organization level1 and ,,ma plan level4 7,,ii7 ,public availability of information ,the ,secretary shall make information collected under subclause 7,i7 publicly available on the internet website of the ,centers for ,medicare ,medicaid ,services4 4 7c7 ,prohibiting certain authorization processes for certain clinically necessary changes and extensions ,section #aheb7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77 is amended by adding at the end the following new paragraph3 7#g7 ,prohibition on requiring certain authorizations ,beginning ,january #a1 #bjbh1 in the case that a ,medicare ,advantage organization offering an ,,ma plan provides approval through a specified authorization 7as defined in subsection 7g77#a77;,c77iii77 for an item or service to be furnished to an individual enrolled in the plan by a provider of services or supplier1 if during the course of furnishing such approved item or service the provider of services or supplier determines that a modification1 extension1 or adjustment to such item or service is clinically necessary1 the ,medicare ,advantage organization may not require a specified authorization 7as defined in subsection 7g77#a77;,c77iii77 to be requested with respect to such item or service as so modified1 extended1 or adjusted4 ,application of the previous sentence shall not limit the authority of the ,medicare ,advantage organization to require documentation or post-service notification of any such modification1 extension1 or adjustment4 4 7d7 ,improvements to the reconsiderations process ,section #aheb7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 in subparagraph 7,a71 by inserting 7or1 with respect to determinations made on or after ,january #a1 #bjbh1 not later than #ad days7 after #fj days2 and 7,b7 by adding at the end the following new subparagraph3 7,c7 ,reconsiderations affirming denials of coverage ,if a reconsideration affirms 7in whole or in part7 a denial of coverage 7including an adverse organization determination under section #dbb4eij of title #db1 ,code of ,federal ,regulations1 or any successor regulation7 made on or after ,january #a1 #bjbh1 with respect to an individual enrolled in an ,,ma plan offered by a ,medicare ,advantage organization1 the ,medicare ,advantage organization shall submit to the independent1 outside entity with a contract under paragraph 7#d7 the case file and written explanation of the decision as expeditiously as the individual's health condition requires1 but not later than #ad days after the date the ,medicare ,advantage organization received the request for the reconsideration4 2 and 7#b7 in paragraph 7#d7-- 7,a7 by striking coverage denials4--,the ,secretary shall contract with and inserting3 coverage denials4-- 7,a7 ,in general ,the ,secretary shall contract with 2 and 7,b7 by adding at the end the following new subparagraphs3 7,b7 ,requirements ,in reviewing and resolving pursuant to subparagraph 7,a7 a reconsideration of a determination of a ,medicare ,advantage organization made on or after ,january #a1 #bjbh1 with respect to an individual enrolled in an ,,ma plan offered by the organization1 the independent1 outside entity shall comply with each of the following requirements3 7i7 ,notice and opportunity to provide supporting documentation ,the entity shall-- 7,i7 not later than #c days after the date of receipt of the relevant case file from the ,medicare ,advantage organization1 submit to the individual1 the representative of the individual 7if applicable71 and the provider of services or supplier furnishing 7or ordering7 the item or service that is the subject of the determination1 a notification regarding the opportunity to submit documentation1 including medical records1 regarding medical necessity2 and 7,,ii7 provide a period of #g days from the date of receipt of such notification for submission of any such documentation4 7ii7 ,decision timeframe ,after reviewing and considering all supporting documentation received before the end of the #g-;day period described in clause 7i77,,ii71 the entity shall issue its decision with respect to such reconsideration as expeditiously as the individual's health condition requires1 but by not later than the applicable number of days specified in subparagraph 7,c7 after the last day of the #g-;day period described in clause 7i77,,ii74 7,c7 ,applicable number of days ,for purposes of subparagraph 7,b77ii71 the applicable number of days specified in this subparagraph is-- 7i7 #ad days1 in the case of a request 7other than with respect to an expedited reconsideration under paragraph 7#c77 for coverage of an item or service that is not a drug for which payment may be made under part ,b2 7ii7 #g days1 in the case of a request 7other than with respect to an expedited reconsideration under paragraph 7#c77 for coverage of a drug for which payment may be made under part ,b2 7iii7 #cj days1 in the case of a request 7other than with respect to an expedited reconsideration under paragraph 7#c77 for payment of an item or service2 and 7iv7 #bd hours1 in the case of a request with respect to an expedited reconsideration under paragraph 7#c74 4 #c4 ,ensuring appropriate oversight of ,medicare ,advantage plans 7a7 ,,mao compliance scoring and accountability program ,section #ahec of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7 is amended by adding at the end the following new subsection3 7p7 ,compliance scoring and enforcement 7#a7 ,payment reductions for ,m,a,os in noncompliance with certain ,,ma program requirements 7,a7 ,in general ,in the case of a ,medicare ,advantage organization with a contract under this part that the ,secretary determines1 in accordance with this subsection1 to be within a compliance tier specified in subparagraph 7,b7 for a performance period with respect to a plan year beginning on or after ,january #a1 #bjbh1 the ,secretary shall reduce the total of the monthly payments made for the plan year under section #ahec7;a77#a7 to the ,medicare ,advantage organization with respect to each ,medicare ,advantage plan offered by such organization by the applicable percent specified under subparagraph 7,b7 with respect to the compliance tier4 7,b7 ,applicable percent specified ,for purposes of subparagraph 7,a71 the applicable percent specified under this subparagraph is as follows3 7i7 ,with respect to the compliance tier described in paragraph 7#e77;,b71 #a4j percent4 7ii7 ,with respect to the compliance tier described in paragraph 7#e77;,c71 #a4e percent4 7iii7 ,with respect to the compliance tier described in paragraph 7#e77;,d71 #b4j percent4 7,c7 ,performance period ,for purposes of this subsection1 the ,secretary shall establish a performance period 7or periods7 for each plan year beginning on or after ,january #a1 #bjbh4 ,such performance period 7or periods7 shall begin and end prior to the beginning of the plan year and be as close as possible to such plan year4 ,in this subsection1 such performance period 7or periods7 for a plan year shall be referred to as the performance period with respect to the plan year4 7#b7 ,establishment of compliance scoring and accountability program ,for purposes of this subsection1 the ,secretary shall establish a ,medicare ,advantage organization compliance scoring and accountability program 7referred to under this subsection as the ,,mao ,compliance ,program7 under which1 for each ,medicare ,advantage organization with a contract under this part and each performance period with respect to a plan year beginning on or after ,january #a1 #bjbh1 the ,secretary-- 7,a7 using the method established under paragraph 7#c77;,a71 shall assess the extent to which the ,medicare ,advantage organization is in compliance with requirements under this part applicable to each compliance category specified under paragraph 7#c77;,b72 7,b7 based on such assessments for each such compliance category1 shall assign a total compliance score to the ,medicare ,advantage organization1 in accordance with paragraph 7#d72 and 7,c7 based on such total compliance score1 shall assign the ,medicare ,advantage organization to a compliance tier described in paragraph 7#e74 7#c7 ,assessment method 7,a7 ,in general ,under the ,,mao ,compliance ,program1 the ,secretary shall establish through notice and comment rulemaking a method to assess1 at the plan level1 the extent to which each ,medicare ,advantage organization offering a ,medicare ,advantage plan is in compliance with requirements under this part applicable to each compliance category specified in subparagraph 7,b74 ,such method shall include the use of audit mechanisms1 reporting requirements1 performance measures established or identified by the ,secretary 7such as applicable measures under the ,,ma ,program ,compliance and ,coverage ,protection ,domain described in section #ahec7o77#h771 and such other methods as specified by the ,secretary4 7,b7 ,compliance categories 7i7 ,in general ,subject to clause 7ii71 under the ,,mao ,compliance ,program1 each of the following shall be a compliance category3 7,i7 ,compliance with timely and real-time specified authorization decision-making requirements1 including compliance with section #aheb7;d77#g7 and paragraphs 7#a77;,c71 7#a77;,d71 and 7#c77;,b77iii77,,ii7 of section #aheb7;g74 7,,ii7 ,compliance with coverage criteria standards1 including the requirements under section #aheb7;g77#g7 and section #aheb7;a77#b77;,d74 7,,iii7 ,compliance with prompt payment requirements1 including compliance with section #aheg7;f74 7,,iv7 ,compliance with restrictions regarding improper retroactive denials and downgrades1 including compliance with section #aheb7;g77#f7 and section #aheg7;e77#g74 7,v7 ,compliance with marketing1 enrollment1 and beneficiary communication requirements1 including subpart ,v of part #dbb of title #db1 ,code of ,federal ,regulations1 or any successor to such regulations4 7,,vi7 ,compliance with other requirements under this part1 including section #aheb7;g77#a77;,e7 and such other requirements as specified by the ,secretary4 7ii7 ,updates ,the ,secretary may1 through notice and comment rulemaking1 revise the compliance categories described in clause 7i71 including by specifying additional categories1 removing categories1 and otherwise updating the requirements that are included in any of such compliance categories4 7#d7 ,scoring methodology ,under the ,,mao ,compliance ,program1 the ,secretary shall1 through notice and comment rulemaking1 establish a methodology to assign a total compliance score 7using a scoring scale of #j to #ajj7 to each ,medicare ,advantage organization for the performance period with respect to a plan year4 ,such total compliance score shall be based on the assessment under paragraph 7#c7 of plan-level compliance with respect to each compliance category described in subparagraph 7,b7 of such paragraph1 with each such category receiving equal weight 7and1 in the case of a ,medicare ,advantage organization offering more than one plan during the performance period1 with each such assessment weighted by the number of individuals enrolled under such plan during such period74 7#e7 ,compliance tiers ,for each plan year beginning on or after ,january #a1 #bjbh1 the ,secretary shall1 based on the total compliance score assigned pursuant to paragraph 7#d7 to a ,medicare ,advantage organization for the performance period with respect to such year1 assign such ,medicare ,advantage organization to one of the following compliance tiers1 as follows3 7,a7 ,compliance tier one1 consisting of ,medicare ,advantage organizations receiving a total score for the performance period of at least #ij4 7,b7 ,compliance tier two1 consisting of ,medicare ,advantage organizations receiving a total score for the performance period of at least #ge but not more than #hi4 7,c7 ,compliance tier three1 consisting of ,medicare ,advantage organizations receiving a total score for the performance period of at least #fj but not more than #gd4 7,d7 ,compliance tier four1 consisting of ,medicare ,advantage organizations receiving a total score for the performance period of less than #fj4 7#f7 ,review ,the ,secretary shall establish a process under which a ,medicare ,advantage organization may seek a review of the total compliance score assigned to the organization pursuant to paragraph 7#d7 for a performance period4 7#g7 ,public disclosures 7,a7 ,in general ,for each plan year beginning on or after ,january #a1 #bjbh1 the ,secretary shall make available on a public website of the ,centers for ,medicare ,medicaid ,services and in an easily understandable format1 information regarding the assessments under the ,,mao ,compliance ,program of compliance during the performance period with respect to the plan year by ,medicare ,advantage organizations1 on the plan level1 with requirements applicable to each compliance category specified in paragraph 7#c77;,b74 ,such information shall include the total compliance score received by each ,medicare ,advantage organization pursuant to paragraph 7#d7 for the performance period4 7,b7 ,opportunity to review and submit corrections ,the ,secretary shall provide for an opportunity for a ,medicare ,advantage organization to review and submit corrections for the information to be made available under subparagraph 7,a7 with respect to such organization prior to such information being made public4 4 7b7 ,expanding the ,,ma star ratings program ,to include an ,,ma program compliance and coverage protection domain 7#a7 ,data collection ,section #aheb7;e77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;e77#c77 is amended-- 7,a7 in subparagraph 7,a77i71 in the first sentence by inserting 1 including1 for plan years beginning on or after ,january #a1 #bjbh1 with respect to measures under the ,,ma ,program ,compliance and ,coverage ,protection ,domain described in section #ahec7o77#h7 after other indices of quality2 and 7,b7 in subparagraph 7,b77i71 by inserting 1 and other than the types of data authorized under subparagraph 7,c7 of section #ahec7o77#h7 for purposes of the ,,ma ,program ,compliance and ,coverage ,protection ,domain described in such section after as of ,november #a1 #bjjc4 7#b7 ,addition of ,,ma program compliance and coverage protection domain to ,,ma star ratings system ,section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 is amended by adding at the end the following new paragraph3 7#h7 ,,ma program compliance and coverage protection domain 7,a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbh1 in addition to any other domain under the #e-star rating system under paragraph 7#d77;,a7 used for determining star ratings of ,medicare ,advantage plans1 the ,secretary shall include under such system an ,,ma ,program ,compliance and ,coverage ,protection ,domain4 7,b7 ,measures ,such domain shall include measures to assess compliance of each ,medicare ,advantage plan with each of the compliance categories specified in section #ahec7p77#c77;,b74 7,c7 ,data ,for purposes of determining star ratings with respect to measures under the ,,ma ,program ,compliance and ,coverage ,protection ,domain1 in addition to sources of data otherwise collected under section #aheb7;e77#c71 the ,secretary may use data collected pursuant to audits1 complaint tracking systems1 appeals data1 determinations made by independent review entities1 and such other sources as specified by the ,secretary4 7,d7 ,application of weighting ,in applying section #dbb4aff7;e7 of title #db1 ,code of ,federal ,regulations1 or a successor regulation1 with respect to the ,,ma ,program ,compliance and ,coverage ,protection ,domain1 the ,secretary shall assign a weight to measures included under such domain that is greater than the weight assigned to measures included under any other domain4 4 #d4 ,guardrails on retrospective clawbacks 7a7 ,application of prompt payment requirements to all claims for which authorization was provided ,section #aheg7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;f77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in the header1 by inserting for items and services furnished by out-of-network providers of services and suppliers after requirement2 and 7,b7 by striking ,a contract and inserting ,subject to paragraph 7#b71 a contract2 7#b7 in paragraph 7#b71 by striking in compliance with paragraph 7#a7 and inserting in compliance with paragraphs 7#a7 and 7#b72 7#c7 by redesignating paragraphs 7#b7 and 7#c7 as paragraphs 7#c7 and 7#d71 respectively2 and 7#d7 by inserting after paragraph 7#a7 the following new paragraph3 7#b7 ,requirement for items and services for which authorization was provided 7,a7 ,in general ,for contract years beginning on or after ,january #a1 #bjbh1 a contract under this part shall require a ,medicare ,advantage organization to provide prompt payment 7consistent with the provisions of sections #ahaf7;c77#b7 and #ahdb7;c77#b77 of qualifying claims submitted for authorized items and services 7as defined in subparagraph 7,b77 furnished to enrollees under the plan1 except that in applying the provisions of such sections-- 7i7 references to not less than #ie percent of all claims submitted shall be treated as references to #ajj percent of all claims submitted2 and 7ii7 every qualifying claim 7as described in subparagraph 7,c77 submitted for an authorized item or service shall be deemed to be a clean claim referred to in such sections4 7,b7 ,authorized item or service defined ,for purposes of this paragraph1 the term authorized item or service means an item or service-- 7i7 that is furnished by a provider of service or supplier to an individual enrolled in a ,medicare ,advantage plan offered by a ,medicare ,advantage organization2 and 7ii7 for which approval was provided by the ,medicare ,advantage organization through a specified authorization 7as defined in section #aheb7;g77#a77;,c77iii774 7,c7 ,qualifying claim described ,for purposes of this paragraph1 a claim for an authorized item or service is a qualifying claim if it includes information sufficient to establish that approval for such item or service was provided as described in subparagraph 7,b77ii74 4 7b7 ,effect of specified authorizations ,section #aheg7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is amended by adding at the end the following new paragraph3 7#g7 ,effect of specified authorizations ,beginning with plan years beginning on or after ,january #a1 #bjbh1 a contract under this section with an ,,ma organization shall require that1 in the case that the ,,ma organization approves the furnishing to an individual enrolled under an ,,ma plan offered by such ,,ma organization of an item or service through a specified authorization 7as defined in section #aheb7;g77#a77;,c77iii77 made during the receipt by the individual of such item or service-- 7,a7 the ,,ma organization may not1 after such approval1 deny coverage of such item or service on the basis of lack of medical necessity and may not reopen such a decision for any reason except for good cause 7as described in sections #dje4ihf and #dbb4faf of title #db1 ,code of ,federal ,regulations 7or any successor regulation77 or if there is reliable evidence of fraud or similar fault 7as such terms are defined in section #dje4ijb of such title 7or any successor regulation771 as determined in accordance with section #dbb4faf of such title 7or any successor regulation72 and 7,b7 the ,,ma organization may not1 after such approval1 change the code assigned with respect to the claim for such item or service such that the amount of payment for such claim would be reduced1 except for good cause 7as described in subparagraph 7,a77 or if there is reliable evidence of fraud or similar fault 7as so described74 4 7c7 ,limitation on use of third-,party post-,claim review entities ,section #aheb7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77 is amended by adding at the end the following new paragraph3 7#f7 ,limitations on use of third-party reviews 7,a7 ,in general ,for contract years beginning on or after ,january #a1 #bjbh1 procedures established by a ,medicare ,advantage organization for making determinations under paragraph 7#a71 reconsiderations under paragraph 7#b71 or expedited determinations or reconsiderations under paragraph 7#c71 and procedures established for providing for any post-payment review process shall-- 7i7 prohibit any third-party entity from conducting a medical necessity review for coverage1 payment1 or post-payment review for such ,medicare ,advantage organization unless-- 7,i7 such review is not with respect to an authorized item or service 7as defined in section #aheg7;f77#b77;,b772 and 7,,ii7 such entity is in compliance with the requirements described in subparagraph 7,b72 7ii7 prohibit the use of any third-party review that is conducted using a routine1 automated process for denials in any such review1 claim denials1 or pattern-based practices of changing a code assigned with respect to a claim for an item or service furnished to individuals enrolled under an ,,ma plan offered by the ,medicare ,advantage organization to a code that would result in a reduction in the amount of payment for such claim after the item or service has been furnished to the individual2 and 7iii7 prohibit any compensation arrangement with any third-party entity that provides for payment or other compensation to such entity based on the number1 percentage1 or amount of specified authorization requests 7as defined in section #aheb7;g77#a77;,c77iii77 that the entity approves1 denies1 or otherwise recommends for approval or denial4 7,b7 ,requirements ,for purposes of subparagraph 7,a71 the requirements specified in this subparagraph1 with respect to a third-party entity and a review described in such subparagraph1 are each of the following3 7i7 ,the entity conducts such review in accordance with audit protocols and appeal rights1 as applicable1 that are specified by the ,secretary4 7ii7 ,the entity complies with audit and public transparency reporting requirements specified by the ,secretary4 4 #e4 ,coverage and medical necessity criteria used by ,medicare ,advantage organizations 7a7 ,codification under the ,medicare ,advantage program of two-,midnight benchmark and presumption rules ,section #aheb7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#a771 as amended by section #b1 is further amended by adding at the end the following new subparagraph3 7,e7 ,application of two-midnight rules ,the procedures under subparagraph 7,a7 shall provide that1 for making determinations described in such subparagraph with respect to hospital and critical access hospital admissions-- 7i7 in determining whether an individual is an inpatient of a hospital or critical access hospital1 the ,medicare ,advantage organization shall continue to apply the provisions of section #dab4c7;d7 of title #db1 ,code of ,federal ,regulations1 or any successor regulation1 in the same manner and to the same extent as such provisions apply with respect to payment under part ,a2 and 7ii7 beginning on ,january #a1 #bjbh1 in conducting medical review activities1 with respect to such admissions1 the ,medicare ,advantage organization shall apply the two-midnight presumption finalized in the rule published by the ,secretary in the ,federal ,register on ,august #ai1 #bjac 7#gh ,fed4 ,reg4 #ejieb71 or any successor regulation1 in the same manner and to the same extent as such provisions apply with respect to payment under part ,a4 4 7b7 ,requiring consistent medical necessity criteria between ,medicare ,advantage and original fee-for-,service 7#a7 ,in general ,section #aheb7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g771 as amended by section #d7;c71 is further amended-- 7,a7 in paragraph 7#b77;,b71 by striking ,a reconsideration relating and inserting ,in accordance with paragraph 7#g77;,c71 a reconsideration relating2 and 7,b7 by adding at the end the following new paragraph3 7#g7 ,medical necessity determined based on ,,ffs reasonable and necessary criteria 7,a7 ,in general ,for purposes of a determination or reconsideration under this subsection made on or after ,january #a1 #bjbh1 or a review made on or after such date by an independent1 outside entity under paragraph 7#d71 with respect to coverage for an item or service furnished to an individual enrolled in an ,,ma plan offered by a ,medicare ,advantage organization1 the ,medicare ,advantage organization or independent1 outside entity1 respectively1 shall not apply criteria for determining the medical necessity of such item or service that is more restrictive than the standards and criteria applied pursuant to section #ahfb7;a77#a7 for determining under parts ,a and ,b whether the item or service is reasonable and necessary4 7,b7 ,certain coverage criteria ,for purposes of a determination or reconsideration under this subsection made on or after ,january #a1 #bjbh1 or a review made on or after such date by an independent1 outside entity under paragraph 7#d71 with respect to coverage of inpatient hospital services furnished by a rehabilitation facility 7as referred to in section #ahhf7;j77#a77;,a77 or long-term care hospital to an individual enrolled in an ,,ma plan offered by a ,medicare ,advantage organization1 the ,medicare ,advantage organization or independent1 outside entity1 respectively1 shall not apply coverage criteria that is more restrictive than the standards and criteria applied under parts ,a and ,b1 including under-- 7i7 paragraphs 7a77#c71 7a77#d71 and 7a77#e7 of section #dab4fbb of title #db1 ,code of ,federal ,regulations 7or any successor to such regulation71 with respect to such a rehabilitation facility2 and 7ii7 paragraphs 7#a71 7#c71 and 7#d7 of section #ahfa7;ccc7 and clauses 7iii7 and 7iv7 of section #ahhf7m77#f77;,a71 with respect to a long-term care hospital4 7,c7 ,personnel ,for purposes of subparagraph 7,a71 a determination1 reconsideration1 or review regarding the medical necessity of an item or service shall be made only by a physician or other health care professional with appropriate expertise1 including education1 with respect to such item or service and the related standards and criteria applied pursuant to section #ahfb7;a77#a74 ,for purposes of subparagraph 7,b71 a determination1 reconsideration1 or review regarding coverage of inpatient hospital services furnished by a facility or hospital described in such subparagraph shall be made only by a physician or other health care professional with appropriate expertise1 including education1 with respect to such services and the related standards and criteria applied pursuant to such subparagraph4 4 7#b7 ,enforcement ,section #aheg7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77 is amended-- 7,a7 by redesignating subparagraph 7,l7 as subparagraph 7,m72 7,b7 by striking or at the end of subparagraph 7,k72 7,c7 by inserting after subparagraph 7,k7 the following subparagraph3 7,l7 fails to comply with section #aheb7;g77#g72 or 2 7,d7 in subparagraph 7,m71 as redesignated by subparagraph 7,a71 by striking subparagraphs 7,a7 through 7,k7 and inserting subparagraphs 7,a7 through 7,l72 and 7,e7 in the matter following such subparagraph 7,m71 by striking subparagraphs 7,a7 through 7,l7 and inserting subparagraphs 7,a7 through 7,m74 7c7 ,requiring transparency in coverage criteria ,section #aheb7;a77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;a77#b77 is amended by adding at the end the following new subparagraph3 7,d7 ,transparency in coverage criteria 7i7 ,requirement ,for plan years beginning on or after ,january #a1 #bjbh1 in order to meet the requirement under paragraph 7#a77;,a71 in the case of an item or service for which there is no national coverage determination1 applicable local coverage determination1 or applicable guidance for coverage provided by the ,secretary1 a ,medicare ,advantage organization offering an ,,ma plan shall-- 7,i7 make a coverage determination with respect to such item or service in accordance with publicly available evidence-based coverage criteria that is published on a public website of the ,medicare ,advantage organization2 and 7,,ii7 submit to the ,secretary information1 with respect to every medical necessity determination made in the absence of such national coverage determination1 applicable local coverage determination1 or applicable guidance for coverage1 specifying the coverage criteria applied under the ,,ma plan4 7ii7 ,use of information ,the ,secretary shall use the information submitted under clause 7i77,,ii7 to prioritize coverage determinations4 4 #f4 ,eliminating inefficiencies in administrative processing by ,medicare ,advantage organizations 7a7 ,applying fee-for-,service prompt payment requirements to ,,ma in-,network services as well as out-of-,network services ,section #aheg7;f77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;f77#a771 as amended by section #d7;a71 is further amended-- 7#a7 in the paragraph heading1 by inserting in-network and before out-of-network2 and 7#b7 by striking if the services or supplies and all that follows through the period at the end and inserting regardless of whether the services or supplies are furnished under a contract between the organization and the provider of services or supplier4 ,a claim that is determined to be a clean claim pursuant to the previous sentence or paragraph 7#b7 may not subsequently be determined to not be a clean claim except under such circumstances and in accordance with such criteria as specified by the ,secretary pursuant to notice and comment rulemaking44 7b7 ,automated review and payment for certain claims ,section #aheg7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;f771 as amended by section #d7;a71 is further amended-- 7#a7 by redesignating paragraphs 7#c7 and 7#d7 as paragraphs 7#d7 and 7#e71 respectively2 and 7#b7 by inserting after paragraph 7#b7 the following new paragraph3 7#c7 ,automated review and payment for certain claims 7,a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbh1 a ,medicare ,advantage organization shall have in place automated payment processes1 in accordance with standards specified by the ,secretary1 for claims described in subparagraph 7,b7 with respect to which the provisions of paragraph 7#a7 or 7#b7 apply4 ,such processes shall provide that such claims shall be automatically processed and paid and shall not be subject to manual claim review1 except in cases for which there is reasonable evidence of fraud4 7,b7 ,specified claims ,for purposes of subparagraph 7,a71 a claim described in this subparagraph is a claim that-- 7i7 is for an authorized item or service 7as defined in paragraph 7#b77;,b772 or 7ii7 is for an item or service identified on the most recent list published pursuant to section #aheb7;g77#a77;,d77iii74 4 #g4 ,modification to network adequacy standards for certain post-acute care providers ,section #aheb7;d77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77#a77 is amended-- 7#a7 in subparagraph 7,d71 by striking and at the end2 7#b7 in subparagraph 7,e71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subparagraph3 7,f7 for plan years beginning on or after ,january #a1 #bjbh1 the organization provides adequate access to long-term care hospitals and inpatient rehabilitation facilities1 as determined in accordance with network adequacy standards specified by the ,secretary4 4