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Improving Seniors’ Timely Access to Care Act of 2025

Introduced May 20, 2025 · Last action Jul 15, 2026 Ordered to be Reported in the Nature of a Substitute by the Yeas and Nays: 42 - 0.

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Summary

This legislation is called the Improving Seniors’ Timely Access to Care Act of 2025. Ordered to be Reported in the Nature of a Substitute by the Yeas and Nays: 42 - 0.

Full bill text

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3514 Introduced in House (IH)]

<DOC>

119th CONGRESS
  1st Session
                                H. R. 3514

     To amend title XVIII of the Social Security Act to establish
   requirements with respect to the use of prior authorization under
                       Medicare Advantage plans.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                              May 20, 2025

   Mr. Kelly of Pennsylvania (for himself, Ms. DelBene, Mr. Joyce of
   Pennsylvania, Mr. Bera, Ms. Van Duyne, Ms. Chu, Mr. Crenshaw, Ms.
Clarke of New York, Mr. Murphy, Ms. Moore of Wisconsin, Mr. Balderson,
  Ms. Schrier, Mr. Yakym, Ms. Sewell, Mrs. Harshbarger, Mr. Larson of
Connecticut, Mr. Carey, Mr. Evans of Pennsylvania, Ms. Malliotakis, Mr.
   Beyer, Ms. Tenney, Ms. Tokuda, Mrs. Miller of West Virginia, Ms.
  Stevens, Mr. Fitzpatrick, Mr. Costa, Mr. Smucker, Ms. Pressley, Mr.
    LaHood, Mr. Davis of North Carolina, Mr. Meuser, Mr. Pocan, Ms.
Salazar, Mr. Fields, Mr. Bacon, Mr. Foster, Mr. Mann, Ms. Brownley, Mr.
  Ciscomani, Mr. Conaway, Mr. Finstad, Ms. Bonamici, Mr. Shreve, Ms.
    Norton, Mrs. Kiggans of Virginia, Mr. Deluzio, Mr. Thompson of
Pennsylvania, Mr. Mrvan, Mr. Moulton, Mr. Case, Ms. McBride, Ms. Ross,
 Ms. Budzinski, Mr. Quigley, Mr. Sorensen, Mr. McGarvey, Ms. Davids of
  Kansas, Ms. Brown, Mr. Crow, Mr. Torres of New York, Ms. Wasserman
Schultz, Mr. Stanton, Mr. Levin, Mr. Keating, Ms. Johnson of Texas, Mr.
 Vicente Gonzalez of Texas, Ms. Goodlander, Ms. Craig, Mr. Goldman of
 New York, Ms. Barragan, Ms. Balint, Mr. Ryan, Ms. Houlahan, and Mrs.
Miller-Meeks) introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on Energy
    and Commerce, for a period to be subsequently determined by the
  Speaker, in each case for consideration of such provisions as fall
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL

     To amend title XVIII of the Social Security Act to establish
   requirements with respect to the use of prior authorization under
                       Medicare Advantage plans.

    Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Improving Seniors' Timely Access to
Care Act of 2025''.

SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR
              AUTHORIZATION UNDER MEDICARE ADVANTAGE PLANS.

    (a) In General.--Section 1852 of the Social Security Act (42 U.S.C.
1395w-22) is amended by adding at the end the following new subsection:
    ``(o) Prior Authorization Requirements.--
            ``(1) In general.--In the case of a Medicare Advantage plan
        that imposes any prior authorization requirement with respect
        to any applicable item or service (as defined in paragraph (5))
        during a plan year, such plan shall--
                    ``(A) beginning with plan years beginning on or
                after January 1, 2028--
                            ``(i) establish the electronic prior
                        authorization program described in paragraph
                        (2); and
                            ``(ii) meet the enrollee protection
                        standards specified pursuant to paragraph (4);
                        and
                    ``(B) beginning with plan years beginning on or
                after January 1, 2027, meet the transparency
                requirements specified in paragraph (3).
            ``(2) Electronic prior authorization program.--
                    ``(A) In general.--For purposes of paragraph
                (1)(A), the electronic prior authorization program
                described in this paragraph is a program that provides
                for the secure electronic transmission of--
                            ``(i) a prior authorization request from a
                        provider or supplier to a Medicare Advantage
                        plan with respect to an applicable item or
                        service to be furnished to an individual and a
                        response, in accordance with this paragraph,
                        from such plan to such provider or supplier;
                        and
                            ``(ii) any supporting documentation
                        relating to such request or response.
                    ``(B) Electronic transmission.--
                            ``(i) Exclusions.--For purposes of this
                        paragraph, a facsimile, a proprietary payer
                        portal that does not meet standards specified
                        by the Secretary, or an electronic form shall
                        not be treated as an electronic transmission
                        described in subparagraph (A).
                            ``(ii) Standards.--An electronic
                        transmission described in subparagraph (A)
                        shall comply with applicable technical
                        standards and other requirements to promote the
                        standardization and streamlining of electronic
                        transactions adopted by the Secretary.
            ``(3) Transparency requirements.--
                    ``(A) In general.--For purposes of paragraph
                (1)(B), the transparency requirements specified in this
                paragraph are, with respect to a Medicare Advantage
                plan, the following:
                            ``(i) The plan, annually and in a manner
                        specified by the Secretary, shall submit to the
                        Secretary the following information:
                                    ``(I) A list of all applicable
                                items and services that were subject to
                                a prior authorization requirement under
                                the plan during the previous plan year.
                                    ``(II) The percentage and number of
                                specified requests (as defined in
                                subparagraph (F)) approved during the
                                previous plan year by the plan in an
                                initial determination and the
                                percentage and number of specified
                                requests denied during such plan year
                                by such plan in an initial
                                determination (both in the aggregate
                                and categorized by each item and
                                service).
                                    ``(III) The percentage and number
                                of specified requests that were denied
                                during the previous plan year by the
                                plan in an initial determination and
                                that were subsequently appealed.
                                    ``(IV) The number of appeals of
                                specified requests resolved during the
                                preceding plan year, and the percentage
                                and number of such resolved appeals
                                that resulted in approval of the
                                furnishing of the item or service that
                                was the subject of such request,
                                categorized by each applicable item and
                                service and categorized by each level
                                of appeal (including judicial review).
                                    ``(V) The percentage and number of
                                specified requests that were denied,
                                and the percentage and number of
                                specified requests that were approved,
                                by the plan during the previous plan
                                year through the utilization of
                                decision support technology, artificial
                                intelligence technology, machine-
                                learning technology, clinical decision-
                                making technology, or any other
                                technology specified by the Secretary.
                                    ``(VI) The average and the median
                                amount of time (in hours) that elapsed
                                during the previous plan year between
                                the submission of a specified request
                                to the plan and a determination by the
                                plan with respect to such request for
                                each such item and service, excluding
                                any such requests that were not
                                submitted with the medical or other
                                documentation required to be submitted
                                by the plan.
                                    ``(VII) The percentage and number
                                of specified requests that were
                                excluded from the calculation described
                                in subclause (VI) based on the plan's
                                determination that such requests were
                                not submitted with the medical or other
                                documentation required to be submitted
                                by the plan.
                                    ``(VIII) Information on each
                                occurrence during the previous plan
                                year in which, during a surgical or
                                medical procedure involving the
                                furnishing of an applicable item or
                                service with respect to which such plan
                                had approved a prior authorization
                                request, the provider or supplier
                                furnishing such item or service
                                determined that a different or
                                additional item or service was
                                medically necessary, including a
                                specification of whether such plan
                                subsequently approved the furnishing of
                                such different or additional item or
                                service.
                                    ``(IX) A disclosure and description
                                of any technology described in
                                subclause (V) that the plan utilized
                                during the previous plan year in making
                                determinations with respect to
                                specified requests.
                                    ``(X) The number of grievances (as
                                described in subsection (f)) received
                                by such plan during the previous plan
                                year that were related to a prior
                                authorization requirement.
                                    ``(XI) Such other information as
                                the Secretary determines appropriate.
                            ``(ii) The plan shall provide--
                                    ``(I) to each provider or supplier
                                who seeks to enter into a contract with
                                such plan to furnish applicable items
                                and services under such plan, the list
                                described in clause (i)(I) and any
                                policies or procedures used by the plan
                                for making determinations with respect
                                to prior authorization requests;
                                    ``(II) to each such provider and
                                supplier that enters into such a
                                contract, access to the criteria used
                                by the plan for making such
                                determinations and an itemization of
                                the medical or other documentation
                                required to be submitted by a provider
                                or supplier with respect to such a
                                request; and
                                    ``(III) to an enrollee of the plan,
                                upon request, access to the criteria
                                used by the plan for making
                                determinations with respect to prior
                                authorization requests for an item or
                                service.
                    ``(B) Option for plan to provide certain additional
                information.--As part of the information described in
                subparagraph (A)(i) provided to the Secretary during a
                plan year, a Medicare Advantage plan may elect to
                include information regarding the percentage and number
                of specified requests made with respect to an
                individual and an item or service that were denied by
                the plan during the preceding plan year in an initial
                determination based on such requests failing to
                demonstrate that such individuals met the clinical
                criteria established by such plan to receive such items
                or services.
                    ``(C) Regulations.--The Secretary shall, through
                notice and comment rulemaking, establish requirements
                for Medicare Advantage plans regarding the provision
                of--
                            ``(i) access to criteria described in
                        subparagraph (A)(ii)(II) to providers of
                        services and suppliers in accordance with such
                        subparagraph; and
                            ``(ii) access to such criteria to enrollees
                        in accordance with subparagraph (A)(ii)(III).
                    ``(D) Publication of information.--The Secretary
                shall publish information described in subparagraph
                (A)(i) and subparagraph (B) on a public website of the
                Centers for Medicare & Medicaid Services. Such
                information shall be so published on an individual plan
                level and may in addition be aggregated in such manner
                as determined appropriate by the Secretary.
                    ``(E) Medpac report.--Not later than 3 years after
                the date information is first submitted under
                subparagraph (A)(i), the Medicare Payment Advisory
                Commission shall submit to Congress a report on such
                information that includes a descriptive analysis of the
                use of prior authorization. As appropriate, the
                Commission should report on statistics including the
                frequency of appeals and overturned decisions. The
                Commission shall provide recommendations, as
                appropriate, on any improvement that should be made to
                the electronic prior authorization programs of Medicare
                Advantage plans.
                    ``(F) Specified request defined.--For purposes of
                this paragraph, the term `specified request' means a
                prior authorization request made with respect to an
                applicable item or service.
            ``(4) Enrollee protection standards.--For purposes of
        paragraph (1)(A)(ii), with respect to the use of prior
        authorization by Medicare Advantage plans for applicable items
        and services, the enrollee protection standards specified in
        this paragraph are--
                    ``(A) the adoption of transparent prior
                authorization programs developed in consultation with
                enrollees and with providers and suppliers with
                contracts in effect with such plans for furnishing such
                items and services under such plans;
                    ``(B) allowing for the waiver or modification of
                prior authorization requirements based on the
                performance of such providers and suppliers in
                demonstrating compliance with such requirements, such
                as adherence to evidence-based medical guidelines and
                other quality criteria; and
                    ``(C) conducting annual reviews of such items and
                services for which prior authorization requirements are
                imposed under such plans through a process that takes
                into account input from enrollees and from providers
                and suppliers with such contracts in effect and is
                based on consideration of prior authorization data from
                previous plan years and analyses of current coverage
                criteria.
            ``(5) Applicable item or service defined.--For purposes of
        this subsection, the term `applicable item or service' means,
        with respect to a Medicare Advantage plan, any item or service
        for which benefits are available under such plan, other than a
        covered part D drug.
            ``(6) Reports to congress.--
                    ``(A) GAO.--Not later than January 1, 2032, the
                Comptroller General of the United States shall submit
                to Congress a report containing an evaluation of the
                implementation of the requirements of this subsection
                and an analysis of issues in implementing such
                requirements faced by Medicare Advantage plans.
                    ``(B) HHS.--
                            ``(i) The secretary.--Not later than the
                        end of the fifth plan year beginning after the
                        date of the enactment of this subsection, and
                        biennially thereafter through the date that is
                        10 years after such date of enactment, the
                        Secretary shall submit to Congress a report
                        containing a description of the information
                        submitted under paragraph (3)(A)(i) during--
                                    ``(I) in the case of the first such
                                report, the fourth plan year beginning
                                after the date of the enactment of this
                                subsection; and
                                    ``(II) in the case of a subsequent
                                report, the 2 plan years preceding the
                                year of the submission of such report.
                            ``(ii) CMS.--Not later than January 1,
                        2028, the Centers for Medicare & Medicaid
                        Services and the Office of National Coordinator
                        for Health Information Technology shall submit
                        to Congress and publish on the internet website
                        of the Centers for Medicare & Medicaid Services
                        a report that--
                                    ``(I) defines the term `real-time
                                decision' and details how the
                                definition for such term may be updated
                                based on any technological advances;
                                    ``(II) using the data submitted to
                                the Secretary under paragraph
                                (3)(A)(i), details a process for real-
                                time decisions for routinely approved
                                items and services for purposes of the
                                electronic prior authorization program
                                described in paragraph (2); and
                                    ``(III) includes an analysis of--
                                            ``(aa) items and services
                                        that are routinely approved;
                                            ``(bb) items and services
                                        identified in item (aa) that
                                        could be eligible for real-time
                                        decisions;
                                            ``(cc) whether establishing
                                        real-time decisions for such
                                        items and services could--

                                                    ``(AA) improve
                                                enrollee access to
                                                benefits under this
                                                part;

                                                    ``(BB) produce
                                                operational
                                                efficiencies for
                                                providers and suppliers
                                                and Medicare Advantage
                                                plans; and

                                                    ``(CC) reduce
                                                health disparities for
                                                Medicare Advantage
                                                enrollees in rural and
                                                low-income communities;
                                                and

                                            ``(dd) how determinations
                                        of routinely approved items and
                                        services made solely through
                                        automation and artificial
                                        intelligence by Medicare
                                        Advantage plans impact patient
                                        access, including disparities
                                        in access for rural and low-
                                        income beneficiaries.''.
    (b) Providing the Secretary Authority To Enforce Timely Responses
for All Prior Authorization Requests Submitted Under Part C.--Section
1852(g) of the Social Security Act (42 U.S.C. 1395w-22(g)) is amended--
            (1) in paragraph (1)(A), by inserting ``and in accordance
        with any timeframe established by the Secretary under paragraph
        (6)'' after ``paragraph (3)'';
            (2) in paragraph (3)(B)(iii), by inserting ``(with respect
        to prior authorization requests submitted on or after the first
        day of the third plan year beginning after the date of the
        enactment of the Improving Seniors' Timely Access to Care Act
        of 2025, any timeframe established by the Secretary under
        paragraph (6))'' after ``72 hours''; and
            (3) by adding at the end the following new paragraph:
            ``(6) Timeframe for response to prior authorization
        requests.--Subject to paragraph (3), the Secretary may
        establish, for purposes of an organization determination made
        with respect to a prior authorization request for an item or
        service to be furnished to an individual, timeframes, such as
        24 hours, for the organization to notify the enrollee (and the
        physician involved, as appropriate) of such determination for--
                    ``(A) a request for expedited determination
                described in paragraph (3)(A);
                    ``(B) a real time decision for routinely approved
                items and services; and
                    ``(C) any other prior authorization request.''.
                                 <all>

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Status

In Committee

  1. 1Introduced
  2. 2Committee
  3. 3Floor
  4. 4Passed
  5. 5Signed

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