II 

118TH CONGRESS 

2D SESSION S. 4518 

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 SENATE OF THE UNITED STATES 

JUNE 12, 2024 

Mr. MARSHALL (for himself, Ms. SINEMA, Mr. THUNE, Mr. BROWN, Ms. CORTEZ MASTO, Ms. COLLINS, and Mrs. FISCHER) introduced the following 

bill; which was read twice and referred to the Committee on Finance 

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. 

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 ‘‘Improving Seniors’ 

5 Timely Access to Care Act of 2024’’. 


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1 SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO 

2 THE USE OF PRIOR AUTHORIZATION UNDER 

3 MEDICARE ADVANTAGE PLANS. 

4 (a) IN GENERAL.—Section 1852 of the Social Secu5 rity Act (42 U.S.C. 1395w–22) is amended by adding at 

6 the end the following new subsection: 

7 ‘‘(o) PRIOR AUTHORIZATION REQUIREMENTS.— 

8 ‘‘(1) IN GENERAL.—In the case of a Medicare 

9 Advantage plan that imposes any prior authorization 

10 requirement with respect to any applicable item or 

11 service (as defined in paragraph (5)) during a plan 

12 year, such plan shall— 

13 ‘‘(A) beginning with plan years beginning 

14 on or after January 1, 2027— 

15 ‘‘(i) establish the electronic prior au16 thorization program described in para17 graph (2); and 

18 ‘‘(ii) meet the enrollee protection 

19 standards specified pursuant to paragraph 

20 (4); and 

21 ‘‘(B) beginning with plan years beginning 

22 on or after January 1, 2026, meet the trans23 parency requirements specified in paragraph 

24 (3). 

25 ‘‘(2) ELECTRONIC PRIOR AUTHORIZATION PRO26 GRAM.— 


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1 ‘‘(A) IN GENERAL.—For purposes of para2 graph (1)(A), the electronic prior authorization 

3 program described in this paragraph is a pro4 gram that provides for the secure electronic 

5 transmission of— 

6 ‘‘(i) a prior authorization request 

7 from a provider of services or supplier to 

8 a Medicare Advantage plan with respect to 

9 an applicable item or service to be fur10 nished to an individual and a response, in 

11 accordance with this paragraph, from such 

12 plan to such provider or supplier; and 

13 ‘‘(ii) any supporting documentation 

14 relating to such request or response. 

15 ‘‘(B) ELECTRONIC TRANSMISSION.— 

16 ‘‘(i) EXCLUSIONS.—For purposes of 

17 this paragraph, a facsimile, a proprietary 

18 payer portal that does not meet standards 

19 specified by the Secretary, or an electronic 

20 form shall not be treated as an electronic 

21 transmission described in subparagraph 

22 (A). 

23 ‘‘(ii) STANDARDS.—An electronic 

24 transmission described in subparagraph 

25 (A) shall comply with applicable technical 


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1 standards and other requirements to pro2 mote the standardization and streamlining 

3 of electronic transactions adopted by the 

4 Secretary. 

5 ‘‘(3) TRANSPARENCY REQUIREMENTS.— 

6 ‘‘(A) IN GENERAL.—For purposes of para7 graph (1)(B), the transparency requirements 

8 specified in this paragraph are, with respect to 

9 a Medicare Advantage plan, the following: 

10 ‘‘(i) The plan, annually and in a man11 ner specified by the Secretary, shall submit 

12 to the Secretary the following information: 

13 ‘‘(I) A list of all applicable items 

14 and services that were subject to a 

15 prior authorization requirement under 

16 the plan during the previous plan 

17 year. 

18 ‘‘(II) The percentage and number 

19 of specified requests (as defined in 

20 subparagraph (F)) approved during 

21 the previous plan year by the plan in 

22 an initial determination and the per23 centage and number of specified re24 quests denied during such plan year 

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1 tion (both in the aggregate and cat2 egorized by each item and service). 

3 ‘‘(III) The percentage and num4 ber of specified requests that were de5 nied during the previous plan year by 

6 the plan in an initial determination 

7 and that were subsequently appealed. 

8 ‘‘(IV) The number of appeals of 

9 specified requests resolved during the 

10 preceding plan year, and the percent11 age and number of such resolved ap12 peals that resulted in approval of the 

13 furnishing of the item or service that 

14 was the subject of such request, cat15 egorized by each applicable item and 

16 service and categorized by each level 

17 of appeal (including judicial review). 

18 ‘‘(V) The percentage and number 

19 of specified requests that were denied, 

20 and the percentage and number of 

21 specified requests that were approved, 

22 by the plan during the previous plan 

23 year through the utilization of deci24 sion support technology, artificial in25 telligence technology, machine-learnVerDate Sep 11 2014 22:12 Aug 01, 2024 Jkt 049200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S4518.IS S4518

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1 ing technology, clinical decision-mak2 ing technology, or any other tech3 nology specified by the Secretary. 

4 ‘‘(VI) The average and the me5 dian amount of time (in hours) that 

6 elapsed during the previous plan year 

7 between the submission of a specified 

8 request to the plan and a determina9 tion by the plan with respect to such 

10 request for each such item and serv11 ice, excluding any such requests that 

12 were not submitted with the medical 

13 or other documentation required to be 

14 submitted by the plan. 

15 ‘‘(VII) The percentage and num16 ber of specified requests that were ex17 cluded from the calculation described 

18 in subclause (VIII) based on the 

19 plan’s determination that such re20 quests were not submitted with the 

21 medical or other documentation re22 quired to be submitted by the plan. 

23 ‘‘(VIII) Information on each oc24 currence during the previous plan 

25 year in which, during a surgical or 


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1 medical procedure involving the fur2 nishing of an applicable item or serv3 ice with respect to which such plan 

4 had approved a prior authorization re5 quest, the provider of services or sup6 plier furnishing such item or service 

7 determined that a different or addi8 tional item or service was medically 

9 necessary, including a specification of 

10 whether such plan subsequently ap11 proved the furnishing of such dif12 ferent or additional item or service. 

13 ‘‘(IX) A disclosure and descrip14 tion of any technology described in 

15 subclause (V) that the plan utilized 

16 during the previous plan year in mak17 ing determinations with respect to 

18 specified requests. 

19 ‘‘(X) The number of grievances 

20 (as described in subsection (f)) re21 ceived by such plan during the pre22 vious plan year that were related to a 

23 prior authorization requirement. 

24 ‘‘(XI) Such other information as 

25 the Secretary determines appropriate. 


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1 ‘‘(ii) The plan shall provide— 

2 ‘‘(I) to each provider or supplier 

3 who seeks to enter into a contract 

4 with such plan to furnish applicable 

5 items and services under such plan, 

6 the list described in clause (i)(I) and 

7 any policies or procedures used by the 

8 plan for making determinations with 

9 respect to prior authorization re10 quests; 

11 ‘‘(II) to each such provider and 

12 supplier that enters into such a con13 tract, access to the criteria used by 

14 the plan for making such determina15 tions and an itemization of the med16 ical or other documentation required 

17 to be submitted by a provider or sup18 plier with respect to such a request; 

19 and 

20 ‘‘(III) to an enrollee of the plan, 

21 upon request, access to the criteria 

22 used by the plan for making deter23 minations with respect to prior au24 thorization requests for an item or 

25 service. 


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1 ‘‘(B) OPTION FOR PLAN TO PROVIDE CER2 TAIN ADDITIONAL INFORMATION.—As part of 

3 the information described in subparagraph 

4 (A)(i) provided to the Secretary during a plan 

5 year, a Medicare Advantage plan may elect to 

6 include information regarding the percentage 

7 and number of specified requests made with re8 spect to an individual and an item or service 

9 that were denied by the plan during the pre10 ceding plan year in an initial determination 

11 based on such requests failing to demonstrate 

12 that such individuals met the clinical criteria 

13 established by such plan to receive such items 

14 or services. 

15 ‘‘(C) REGULATIONS.—The Secretary shall, 

16 through notice and comment rulemaking, estab17 lish requirements for Medicare Advantage plans 

18 regarding the provision of— 

19 ‘‘(i) access to criteria described in 

20 subparagraph (A)(ii)(II) to providers of 

21 services and suppliers in accordance with 

22 such subparagraph; and 

23 ‘‘(ii) access to such criteria to enroll24 ees in accordance with subparagraph 

25 (A)(ii)(III). 


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1 ‘‘(D) PUBLICATION OF INFORMATION.— 

2 The Secretary shall publish information de3 scribed in subparagraph (A)(i) and subpara4 graph (B) on a public website of the Centers 

5 for Medicare & Medicaid Services. Such infor6 mation shall be so published on an individual 

7 plan level and may in addition be aggregated in 

8 such manner as determined appropriate by the 

9 Secretary. 

10 ‘‘(E) MEDPAC REPORT.—Not later than 3 

11 years after the date information is first sub12 mitted under subparagraph (A)(i), the Medicare 

13 Payment Advisory Commission shall submit to 

14 Congress a report on such information that in15 cludes a descriptive analysis of the use of prior 

16 authorization. As appropriate, the Commission 

17 should report on statistics including the fre18 quency of appeals and overturned decisions. 

19 The Commission shall provide recommenda20 tions, as appropriate, on any improvement that 

21 should be made to the electronic prior author22 ization programs of Medicare Advantage plans. 

23 ‘‘(F) SPECIFIED REQUEST DEFINED.—For 

24 purposes of this paragraph, the term ‘specified 

25 request’ means a prior authorization request 


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1 made with respect to an applicable item or serv2 ice. 

3 ‘‘(4) ENROLLEE PROTECTION STANDARDS.— 

4 For purposes of paragraph (1)(A)(ii), with respect 

5 to the use of prior authorization by Medicare Advan6 tage plans for applicable items and services, the en7 rollee protection standards specified in this para8 graph are— 

9 ‘‘(A) the adoption of transparent prior au10 thorization programs developed in consultation 

11 with enrollees and with providers and suppliers 

12 with contracts in effect with such plans for fur13 nishing such items and services under such 

14 plans; 

15 ‘‘(B) allowing for the waiver or modifica16 tion of prior authorization requirements based 

17 on the performance of such providers and sup18 pliers in demonstrating compliance with such 

19 requirements, such as adherence to evidence20 based medical guidelines and other quality cri21 teria; and 

22 ‘‘(C) conducting annual reviews of such 

23 items and services for which prior authorization 

24 requirements are imposed under such plans 

25 through a process that takes into account input 


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1 from enrollees and from providers and suppliers 

2 with such contracts in effect and is based on 

3 consideration of prior authorization data from 

4 previous plan years and analyses of current cov5 erage criteria. 

6 ‘‘(5) APPLICABLE ITEM OR SERVICE DE7 FINED.—For purposes of this subsection, the term 

8 ‘applicable item or service’ means, with respect to a 

9 Medicare Advantage plan, any item or service for 

10 which benefits are available under such plan, other 

11 than a covered part D drug. 

12 ‘‘(6) REPORTS TO CONGRESS.— 

13 ‘‘(A) GAO.—Not later than January 1, 

14 2028, the Comptroller General of the United 

15 States shall submit to Congress a report con16 taining an evaluation of the implementation of 

17 the requirements of this subsection and an 

18 analysis of issues in implementing such require19 ments faced by Medicare Advantage plans. 

20 ‘‘(B) HHS.— 

21 ‘‘(i) THE SECRETARY.—Not later than 

22 the end of the fifth plan year beginning 

23 after the date of the enactment of this sub24 section, and biennially thereafter through 

25 the date that is 10 years after such date 


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1 of enactment, the Secretary shall submit to 

2 Congress a report containing a description 

3 of the information submitted under para4 graph (3)(A)(i) during— 

5 ‘‘(I) in the case of the first such 

6 report, the fourth plan year beginning 

7 after the date of the enactment of this 

8 subsection; and 

9 ‘‘(II) in the case of a subsequent 

10 report, the 2 plan years preceding the 

11 year of the submission of such report. 

12 ‘‘(ii) CMS.—Not later than January 

13 1, 2027, the Centers for Medicare & Med14 icaid Services and the Office of National 

15 Coordinator for Health Information Tech16 nology shall submit to Congress and pub17 lish on the internet website of the Centers 

18 for Medicare & Medicaid Services a report 

19 that— 

20 ‘‘(I) defines the term ‘real-time 

21 decision’ and details how the defini22 tion for such term may be updated 

23 based on any technological advances; 

24 ‘‘(II) using the data submitted to 

25 the Secretary under paragraph 


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1 (3)(A)(i), details a process for real2 time decisions for items and services 

3 for routinely approved services for 

4 purposes of the electronic prior au5 thorization program described in 

6 paragraph (2); and 

7 ‘‘(III) includes an analysis of— 

8 ‘‘(aa) items and services 

9 that are routinely approved; 

10 ‘‘(bb) items and services 

11 identified in item (aa) that could 

12 be eligible for real-time decisions; 

13 ‘‘(cc) how establishing real14 time decisions for such items and 

15 services could— 

16 ‘‘(AA) improve enrollee 

17 access to benefits under this 

18 part; 

19 ‘‘(BB) produce oper20 ational efficiencies for pro21 viders of services and sup22 pliers and Medicare Advan23 tage plans; and 

24 ‘‘(CC) reduce health 

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1 vantage enrollees in rural 

2 and low-income commu3 nities; and 

4 ‘‘(dd) how the use of auto5 mated decision making and artifi6 cial intelligence by Medicare Ad7 vantage plans impact patient ac8 cess, including disparities in ac9 cess for rural and low-income 

10 beneficiaries, to routinely ap11 proved items and services.’’. 

12 (b) PROVIDING THE SECRETARY AUTHORITY TO EN13 FORCE TIMELY RESPONSES FOR ALL PRIOR AUTHORIZA14 TION REQUESTS SUBMITTED UNDER PART C.—Section 

15 1852(g) of the Social Security Act (42 U.S.C. 1395w– 

16 22(g)) is amended— 

17 (1) in paragraph (1)(A), by inserting ‘‘and in 

18 accordance with any timeframe established by the 

19 Secretary under paragraph (6)’’ after ‘‘paragraph 

20 (3)’’; 

21 (2) in paragraph (3)(B)(iii), by inserting ‘‘(or, 

22 subject to subsection (o), with respect to prior au23 thorization requests submitted on or after the first 

24 day of the third plan year beginning after the date 

25 of the enactment of the Improving Seniors’ Timely 


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1 Access to Care Act of 2024, any timeframe estab2 lished by the Secretary under paragraph (6))’’ after 

3 ‘‘72 hours’’; and 

4 (3) by adding at the end the following new 

5 paragraph: 

6 ‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU7 THORIZATION REQUESTS.—Subject to paragraph (3) 

8 and subsection (o), the Secretary may establish, for 

9 purposes of an organization determination made 

10 with respect to a prior authorization request for an 

11 item or service to be furnished to an individual, 

12 timeframes, such as 24 hours, for the organization 

13 to notify the enrollee (and the physician involved, as 

14 appropriate) of such determination for— 

15 ‘‘(A) a request for expedited determination 

16 described in paragraph (3)(A); 

17 ‘‘(B) a real time decision for routinely ap18 proved items and services; and 

19 ‘‘(C) any other prior authorization re20 quest.’’. 

Æ 


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