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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 5612 Introduced in Senate (IS)]

<DOC>

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.

    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 Relief Act''.

SEC. 2. MEDICARE ADVANTAGE PROGRAM PRIOR AUTHORIZATION REFORMS.

    (a) Medicare Advantage.--Section 1859 of the Social Security Act 
(42 U.S.C. 1395w-28) is amended by adding at the end the following new 
subsection:
    ``(j) Prior Authorization Requirements.--
            ``(1) Audit.--Not later than January 1, 2026, the Secretary 
        shall conduct an audit of prior authorization requirements for 
        items and services furnished, and covered part D drugs 
        prescribed, to enrollees under this part in order to identify 
        the items and services and covered part D drugs that the 
        Secretary determines meet each of the following criteria:
                    ``(A) Reimbursement for such item or service or 
                covered part D drug under this part is in the top 10 
                percent of reimbursements for all items and services 
                and covered part D drugs under this part.
                    ``(B) There is sufficient clinical evidence to 
                establish a standard medical policy for the prior 
                authorization process for such item or service or 
                covered part D drug.
                    ``(C) Prior authorization for such item or service 
                or covered part D drug requires an excessive number of 
                steps to complete the required protocols.
            ``(2) Standardized requirements.--Not later than October 1, 
        2026, taking into account the results of the audit conducted 
        under paragraph (1), the Secretary shall promulgate a final 
        rule to standardize the prior authorization requirements 
        (including supplemental forms) for items and services and 
        covered part D drugs identified under paragraph (1) across all 
        Medicare Advantage plans, including MA-PD plans.
            ``(3) Exemption from requirements.--
                    ``(A) In general.--Subject to subparagraph (B), if 
                an accountable care organization satisfies the savings 
                requirements under section 1899(d)(1)(B) for a 
                performance year beginning on or after January 1, 2026, 
                in the case of an ACO professional (as defined in 
                section 1899(h)(1)) participating in such ACO with a 
                patient load that includes at least 20 percent of 
                Medicare fee-for-service beneficiaries (as defined in 
                section 1899(h)(2)) assigned to such accountable care 
                organization, the prior authorization requirements for 
                the items and services and covered part D drugs 
                identified under paragraph (1) shall not apply when 
                such items and services are furnished by, or such 
                covered part D drugs are prescribed by, such ACO 
                professional during the succeeding year to an enrollee 
                under this part.
                    ``(B) Limitation.--The Secretary shall establish a 
                process under which an MA organization offering a 
                Medicare Advantage plan (including an MA-PD plan) may 
                request that the exemption under subparagraph (A) not 
                apply with respect to items and services and covered 
                part D drugs furnished to enrollees under the plan and 
                that the prior authorization requirements that would 
                otherwise apply under the plan for such items and 
                services and covered part D drugs continue to apply.''.
                                 <all>
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