Prior Authorization Accountability Act

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9396 Introduced in House (IH)]

<DOC>

119th CONGRESS
  2d Session
                                H. R. 9396

  To amend title XXVII of the Public Health Service Act, the Employee
 Retirement Income Security Act of 1974, and the Internal Revenue Code
        of 1986 to require the displaying of claim denial rates.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             June 23, 2026

Mr. Goldman of Texas introduced the following bill; which was referred
    to the Committee on Energy and Commerce, and in addition to the
Committees on Ways and Means, and Education and Workforce, 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 XXVII of the Public Health Service Act, the Employee
 Retirement Income Security Act of 1974, and the Internal Revenue Code
        of 1986 to require the displaying of claim denial rates.

    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 ``Prior Authorization Accountability
Act''.

SEC. 2. DISPLAYING CLAIM DENIAL RATES.

    (a) PHSA.--Part D of title XXVII of the Public Health Service Act
(42 U.S.C. 300gg-111 et seq.) is amended by adding at the end the
following new section:

``SEC. 2799A-12. PRIOR AUTHORIZATION TRANSPARENCY REQUIREMENTS.

    ``(a) In General.--In the case of a group health plan or health
insurance issuer offering group or individual health insurance coverage
that imposes any prior authorization requirement with respect to an
item or service furnished under such plan or coverage during a plan
year beginning on or after January 1, 2027, such plan or issuer shall,
at a time and in a manner specified by the Secretary, submit to the
Secretary (and, in the case of group or individual health insurance
coverage, if such coverage was offered through an Exchange established
under subtitle D of title I of the Patient Protection and Affordable
Care Act, to such Exchange) and make available on a public website of
the plan or issuer the following information:
            ``(1) A list of all items and services that were subject to
        a prior authorization requirement under the plan or coverage
        during such plan year.
            ``(2) The percentage and number of prior authorization
        requests approved during such plan year by the plan or issuer
        in an initial determination and the percentage and number of
        prior authorization requests denied during such plan year by
        such plan or issuer in an initial determination (both in the
        aggregate and categorized by each item and service).
            ``(3) The percentage and number of prior authorization
        requests that were denied during such plan year by the plan or
        issuer in an initial determination and that were subsequently
        appealed.
            ``(4) The percentage and number of resolved appeals of such
        requests that resulted in approval of the furnishing of the
        item or service that was the subject of such request,
        categorized by each item and service and categorized by each
        level of appeal (including judicial review).
            ``(5) The average and the median amount of time (in hours)
        that elapsed during such plan year between the submission of a
        prior authorization request to the plan or issuer and a
        determination by the plan or issuer 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 or issuer.
            ``(6) The percentage and number of prior authorization
        requests that were denied, and the percentage and number of
        prior authorization requests that were approved, by the plan or
        issuer during such plan year solely 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.
            ``(7) A disclosure and description of any technology
        described in paragraph (6) that the plan or issuer utilized
        during such plan year in making determinations with respect to
        prior authorization requests.
    ``(b) Manner of Publication.--Information submitted and published
by a group health plan or health insurance issuer offering group or
individual health insurance coverage under subsection (a) shall be so
submitted and published on a group health plan and health insurance
coverage level and shall in addition, if determined appropriate by the
Secretary, be so submitted and published in the aggregate in such
manner as specified by the Secretary (such as across all group health
plans of the sponsor of such plan or all health insurance coverage
offered by such issuer that are offered within the same insurance
market (as specified in subclause (I), (II), (III), or (IV) of section
2799A-1(a)(3)(E)(iv))).''.
    (b) ERISA.--
            (1) In general.--Subpart B of part 7 of subtitle B of title
        I of the Employee Retirement Income Security Act of 1974 (29
        U.S.C. 1185 et seq.) is amended by adding at the end the
        following new section:

``SEC. 727. PRIOR AUTHORIZATION TRANSPARENCY REQUIREMENTS.

    ``(a) In General.--In the case of a group health plan or health
insurance issuer offering group health insurance coverage that imposes
any prior authorization requirement with respect to an item or service
furnished under such plan or coverage during a plan year beginning on
or after January 1, 2027, such plan or issuer shall, at a time and in a
manner specified by the Secretary, submit to the Secretary and make
available on a public website of the plan or issuer the following
information:
            ``(1) A list of all items and services that were subject to
        a prior authorization requirement under the plan or coverage
        during such plan year.
            ``(2) The percentage and number of prior authorization
        requests approved during such plan year by the plan or issuer
        in an initial determination and the percentage and number of
        prior authorization requests denied during such plan year by
        such plan or issuer in an initial determination (both in the
        aggregate and categorized by each item and service).
            ``(3) The percentage and number of prior authorization
        requests that were denied during such plan year by the plan or
        issuer in an initial determination and that were subsequently
        appealed.
            ``(4) The percentage and number of resolved appeals of such
        requests that resulted in approval of the furnishing of the
        item or service that was the subject of such request,
        categorized by each item and service and categorized by each
        level of appeal (including judicial review).
            ``(5) The average and the median amount of time (in hours)
        that elapsed during such plan year between the submission of a
        prior authorization request to the plan or issuer and a
        determination by the plan or issuer 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 or issuer.
            ``(6) The percentage and number of prior authorization
        requests that were denied, and the percentage and number of
        prior authorization requests that were approved, by the plan or
        issuer during such plan year solely 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.
            ``(7) A disclosure and description of any technology
        described in paragraph (6) that the plan or issuer utilized
        during such plan year in making determinations with respect to
        prior authorization requests.
    ``(b) Manner of Publication.--Information submitted and published
by a group health plan or health insurance issuer offering group health
insurance coverage under subsection (a) shall be so submitted and
published on a group health plan and health insurance coverage level
and shall in addition, if determined appropriate by the Secretary, be
so submitted and published in the aggregate in such manner as specified
by the Secretary (such as across all group health plans of the sponsor
of such plan or all health insurance coverage offered by such issuer
that are offered within the same insurance market (as specified in
subclause (I), (II), (III), or (IV) of section 716(a)(3)(E)(iv))).''.
            (2) Clerical amendment.--The table of contents in section 1
        of the Employee Retirement Income Security Act of 1974 (29
        U.S.C. 1001 note) is amended by inserting after the item
        relating to section 726 the following new item:

``Sec. 727. Prior authorization transparency requirements.''.
    (c) IRC.--
            (1) In general.--Subchapter B of chapter 100 of the
        Internal Revenue Code of 1986 is amended by adding at the end
        the following new section:

``SEC. 9827. PRIOR AUTHORIZATION TRANSPARENCY REQUIREMENTS.

    ``(a) In General.--In the case of a group health plan that imposes
any prior authorization requirement with respect to an item or service
furnished under such plan during a plan year beginning on or after
January 1, 2027, such plan shall, at a time and in a manner specified
by the Secretary, submit to the Secretary and make available on a
public website of the plan the following information:
            ``(1) A list of all items and services that were subject to
        a prior authorization requirement under the plan during such
        plan year.
            ``(2) The percentage and number of prior authorization
        requests approved during such plan year by the plan in an
        initial determination and the percentage and number of prior
        authorization requests denied during such plan year by such
        plan in an initial determination (both in the aggregate and
        categorized by each item and service).
            ``(3) The percentage and number of prior authorization
        requests that were denied during such plan year by the plan in
        an initial determination and that were subsequently appealed.
            ``(4) The percentage and number of resolved appeals of such
        requests that resulted in approval of the furnishing of the
        item or service that was the subject of such request,
        categorized by each item and service and categorized by each
        level of appeal (including judicial review).
            ``(5) The average and the median amount of time (in hours)
        that elapsed during such plan year between the submission of a
        prior authorization 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.
            ``(6) The percentage and number of prior authorization
        requests that were denied, and the percentage and number of
        prior authorization requests that were approved, by the plan
        during such plan year solely 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.
            ``(7) A disclosure and description of any technology
        described in paragraph (6) that the plan utilized during such
        plan year in making determinations with respect to prior
        authorization requests.
    ``(b) Manner of Publication.--Information submitted and published
by a group health plan under subsection (a) shall be so published on a
group health plan level and shall in addition, if determined
appropriate by the Secretary, be so submitted and published in the
aggregate in such manner as specified by the Secretary (such as across
all group health plans of the sponsor of such plan that are offered
within the same insurance market (as specified in subclause (I), (II),
(III), or (IV) of section 9816(a)(3)(E)(iv))).''.
            (2) Clerical amendment.--The table of sections for
        subchapter B of chapter 100 of the Internal Revenue Code of
        1986 is amended by adding at the end the following new item:

``Sec. 9827. Prior authorization transparency requirements.''.

SEC. 3. PROMOTING COMPARABILITY OF QUALIFIED HEALTH PLANS OFFERED
              THROUGH AN EXCHANGE.

    Section 1311(d)(4)(C) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18031(d)(4)(C)) is amended--
            (1) by striking ``website through which'' and inserting the
        following: ``website--
                            ``(i) through which'';
            (2) in clause (i), as so inserted, by striking the
        semicolon and inserting ``; and''; and
            (3) by adding at the end the following new clause:
                            ``(ii) that includes, as part of such
                        comparative information for enrollments for
                        plan years beginning on or after January 1,
                        2029, in the case a qualified health plan
                        offered through such Exchange for such plan
                        year was offered through such Exchange for a
                        previous plan year, the most recent information
                        submitted to such Exchange with respect to such
                        plan by the health insurance issuer of such
                        plan under section 2799A-12 of the Public
                        Health Service Act;''.
                                 <all>