Today, the
Improving Seniors' Timely Access to Care Act (H.R. 3514), which addresses issues surrounding prior authorizations in Medicare Advantage (MA), passed out of the House Ways and Means Committee.
AHCA/NCAL endorses this legislation.What It Does H.R. 3514 formalizes many of the Centers for Medicare & Medicaid Services' existing prior authorization requirements in statute, reinforcing their permanence and helping to promote more consistent implementation and adherence across
MA plans.
The key reporting requirements this act would cover include services requiring:
- Services requiring prior authorization
- A list of every item and service subject to prior authorization during the previous plan year.
- Approval and denial rates
- The number and percentage of prior authorization requests approved and denied.
- Reported both in the aggregate and broken down by each individual item/service.
- Appeal activity
- The percentage and number of denied requests that were appealed.
- Appeal outcomes
- The number of appeals resolved.
- The percentage and number of appeals that resulted in the service being approved.
- Reported by item/service and by each level of appeal, including judicial review.
- Use of AI and decision-support technology
- The percentage and number of approvals and denials made using AI, machine learning, clinical decision-support tools, or similar technologies.
- A description of the technologies used.
- Decision timeframes
- The average and median number of hours from receipt of a complete request to the plan's determination.
- Reported by item/service.
- Incomplete requests
- The percentage and number of requests excluded from the turnaround-time calculation because the plan determined the submission lacked required documentation.
- Changes during treatment
- Reporting on instances where a provider determined that a different or additional service was medically necessary after prior authorization had already been approved (e.g., during surgery), including whether the plan ultimately approved the additional service.
What Comes Next The bill now goes to the House Energy and Commerce Committee before hopefully moving to receive a vote on the House floor. This bill has roughly 290 co-sponsors, meaning that two-thirds of the House already support this legislation.
AHCA/NCAL will continue to monitor developments and keep members informed of any significant updates related to this matter.