The House passed the “Improving Seniors’ Timely Access to Care Act” (HR 3173) to establish requirements and standards relating to prior authorization processes under Medicare Advantage (MA) plans.
The bill requires plans to establish an electronic prior authorization program that provides real-time decisions in response to requests for items and services that are routinely approved. To systematize the process, HHS will adopt standards for the electronic transmissions in consultation with unspecified standard setting organizations, health care professionals, Medicare Advantage organizations and health information technology software vendors that ensure the transmissions support attachments and use interoperable health IT technology certified by the Office of the National Coordinator for HIT (ONC). The prior authorization electronic transmission will meet the standards for information and data elements in section 1173 of the Social Security Act and other requirement specified by HHS.[1]
Additionally, the plans must publish annually specified prior authorization information, such as the percentage of requests approved and average response times. The legislation allows plans to waive or modify prior authorization requirements based on provider or supplier performance, or adherence to evidence-based medical guidelines and other quality criteria.
A Senate version of the bill (S 3018) has 43 bipartisan cosponsors (23D, 22R), but it is unclear if the Senate will consider the bill during the lame-duck session in December. CMS would need to begin work on the transmission standards almost immediately in 2023 and the regulatory process by early 2024 for inclusion in plan year 2025.
However, given widespread support for the bill, if it does not pass this session, it is likely to be introduced next year.
[1] section 1173 of the Act requires the Secretary to adopt standards for code sets for specified health care transaction, security standards to protect health care information, standards for electronic signatures, and standards for the transmission of data elements needed for the coordination of benefits and sequential processing of claims.