II 

118TH CONGRESS 

2D SESSION S. 5612 

To amend part C of title XVIII of the Social Security Act to provide 

for prior authorization reforms under the Medicare Advantage program. 

IN THE SENATE OF THE UNITED STATES 

DECEMBER 19 (legislative day, DECEMBER 16), 2024 

Mr. WHITEHOUSE introduced the following bill; which was read twice and 

referred to the Committee on Finance 

A BILL 

To amend part C of title XVIII of the Social Security Act 

to provide for prior authorization reforms under the 

Medicare Advantage program. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Prior Authorization 

5 Relief Act’’. 

6 SEC. 2. MEDICARE ADVANTAGE PROGRAM PRIOR AUTHOR7 IZATION REFORMS. 

8 (a) MEDICARE ADVANTAGE.—Section 1859 of the 

9 Social Security Act (42 U.S.C. 1395w–28) is amended by 

10 adding at the end the following new subsection: 


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1 ‘‘(j) PRIOR AUTHORIZATION REQUIREMENTS.— 

2 ‘‘(1) AUDIT.—Not later than January 1, 2026, 

3 the Secretary shall conduct an audit of prior author4 ization requirements for items and services fur5 nished, and covered part D drugs prescribed, to en6 rollees under this part in order to identify the items 

7 and services and covered part D drugs that the Sec8 retary determines meet each of the following criteria: 

9 ‘‘(A) Reimbursement for such item or serv10 ice or covered part D drug under this part is 

11 in the top 10 percent of reimbursements for all 

12 items and services and covered part D drugs 

13 under this part. 

14 ‘‘(B) There is sufficient clinical evidence to 

15 establish a standard medical policy for the prior 

16 authorization process for such item or service or 

17 covered part D drug. 

18 ‘‘(C) Prior authorization for such item or 

19 service or covered part D drug requires an ex20 cessive number of steps to complete the re21 quired protocols. 

22 ‘‘(2) STANDARDIZED REQUIREMENTS.—Not 

23 later than October 1, 2026, taking into account the 

24 results of the audit conducted under paragraph (1), 

25 the Secretary shall promulgate a final rule to standVerDate Sep 11 2014 18:56 Jan 25, 2025 Jkt 059200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S5612.IS S5612

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1 ardize the prior authorization requirements (includ2 ing supplemental forms) for items and services and 

3 covered part D drugs identified under paragraph (1) 

4 across all Medicare Advantage plans, including MA– 

5 PD plans. 

6 ‘‘(3) EXEMPTION FROM REQUIREMENTS.— 

7 ‘‘(A) IN GENERAL.—Subject to subpara8 graph (B), if an accountable care organization 

9 satisfies the savings requirements under section 

10 1899(d)(1)(B) for a performance year begin11 ning on or after January 1, 2026, in the case 

12 of an ACO professional (as defined in section 

13 1899(h)(1)) participating in such ACO with a 

14 patient load that includes at least 20 percent of 

15 Medicare fee-for-service beneficiaries (as de16 fined in section 1899(h)(2)) assigned to such 

17 accountable care organization, the prior author18 ization requirements for the items and services 

19 and covered part D drugs identified under para20 graph (1) shall not apply when such items and 

21 services are furnished by, or such covered part 

22 D drugs are prescribed by, such ACO profes23 sional during the succeeding year to an enrollee 

24 under this part. 


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1 ‘‘(B) LIMITATION.—The Secretary shall 

2 establish a process under which an MA organi3 zation offering a Medicare Advantage plan (in4 cluding an MA–PD plan) may request that the 

5 exemption under subparagraph (A) not apply 

6 with respect to items and services and covered 

7 part D drugs furnished to enrollees under the 

8 plan and that the prior authorization require9 ments that would otherwise apply under the 

10 plan for such items and services and covered 

11 part D drugs continue to apply.’’. 

Æ 


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