II 

118TH CONGRESS 

2D SESSION S. 4532 

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 13, 2024 

Mr. MARSHALL (for himself, Ms. SINEMA, Mr. THUNE, Mr. BROWN, Mrs. 

BLACKBURN, Mr. WHITEHOUSE, Mr. CASSIDY, Ms. HASSAN, Mr. TILLIS, 

Mr. CARPER, Mr. CORNYN, Mr. CASEY, Mr. BOOZMAN, Ms. STABENOW, 

Mr. MORAN, Ms. KLOBUCHAR, Mr. VANCE, Mrs. GILLIBRAND, Mr. 

BUDD, Mr. KAINE, Mr. HAWLEY, Mrs. SHAHEEN, Mrs. HYDE-SMITH, 

Mr. KELLY, Mr. CRAMER, Ms. ROSEN, Mr. BRAUN, Mr. HEINRICH, Mr. 

SCHMITT, Mr. HICKENLOOPER, Mr. RUBIO, Mr. PETERS, Mr. ROUNDS, 

Mr. WELCH, Mr. HOEVEN, Mr. PADILLA, Ms. COLLINS, Mr. 

BLUMENTHAL, Mrs. FISCHER, Mr. WARNOCK, Mr. SCHATZ, Mr. 

MERKLEY, Mr. FETTERMAN, Ms. WARREN, and Ms. CORTEZ MASTO) 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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Improving Seniors’ 

3 Timely Access to Care Act of 2024’’. 

4 SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO 

5 THE USE OF PRIOR AUTHORIZATION UNDER 

6 MEDICARE ADVANTAGE PLANS. 

7 (a) IN GENERAL.—Section 1852 of the Social Secu8 rity Act (42 U.S.C. 1395w–22) is amended by adding at 

9 the end the following new subsection: 

10 ‘‘(o) PRIOR AUTHORIZATION REQUIREMENTS.— 

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

12 Advantage plan that imposes any prior authorization 

13 requirement with respect to any applicable item or 

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

15 year, such plan shall— 

16 ‘‘(A) beginning with plan years beginning 

17 on or after January 1, 2027— 

18 ‘‘(i) establish the electronic prior au19 thorization program described in para20 graph (2); and 

21 ‘‘(ii) meet the enrollee protection 

22 standards specified pursuant to paragraph 

23 (4); and 

24 ‘‘(B) beginning with plan years beginning 

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1 parency requirements specified in paragraph 

2 (3). 

3 ‘‘(2) ELECTRONIC PRIOR AUTHORIZATION PRO4 GRAM.— 

5 ‘‘(A) IN GENERAL.—For purposes of para6 graph (1)(A), the electronic prior authorization 

7 program described in this paragraph is a pro8 gram that provides for the secure electronic 

9 transmission of— 

10 ‘‘(i) a prior authorization request 

11 from a provider of services or supplier to 

12 a Medicare Advantage plan with respect to 

13 an applicable item or service to be fur14 nished to an individual and a response, in 

15 accordance with this paragraph, from such 

16 plan to such provider or supplier; and 

17 ‘‘(ii) any supporting documentation 

18 relating to such request or response. 

19 ‘‘(B) ELECTRONIC TRANSMISSION.— 

20 ‘‘(i) EXCLUSIONS.—For purposes of 

21 this paragraph, a facsimile, a proprietary 

22 payer portal that does not meet standards 

23 specified by the Secretary, or an electronic 

24 form shall not be treated as an electronic 


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1 transmission described in subparagraph 

2 (A). 

3 ‘‘(ii) STANDARDS.—An electronic 

4 transmission described in subparagraph 

5 (A) shall comply with applicable technical 

6 standards and other requirements to pro7 mote the standardization and streamlining 

8 of electronic transactions adopted by the 

9 Secretary. 

10 ‘‘(3) TRANSPARENCY REQUIREMENTS.— 

11 ‘‘(A) IN GENERAL.—For purposes of para12 graph (1)(B), the transparency requirements 

13 specified in this paragraph are, with respect to 

14 a Medicare Advantage plan, the following: 

15 ‘‘(i) The plan, annually and in a man16 ner specified by the Secretary, shall submit 

17 to the Secretary the following information: 

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

19 and services that were subject to a 

20 prior authorization requirement under 

21 the plan during the previous plan 

22 year. 

23 ‘‘(II) The percentage and number 

24 of specified requests (as defined in 

25 subparagraph (F)) approved during 


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1 the previous plan year by the plan in 

2 an initial determination and the per3 centage and number of specified re4 quests denied during such plan year 

5 by such plan in an initial determina6 tion (both in the aggregate and cat7 egorized by each item and service). 

8 ‘‘(III) The percentage and num9 ber of specified requests that were de10 nied during the previous plan year by 

11 the plan in an initial determination 

12 and that were subsequently appealed. 

13 ‘‘(IV) The number of appeals of 

14 specified requests resolved during the 

15 preceding plan year, and the percent16 age and number of such resolved ap17 peals that resulted in approval of the 

18 furnishing of the item or service that 

19 was the subject of such request, cat20 egorized by each applicable item and 

21 service and categorized by each level 

22 of appeal (including judicial review). 

23 ‘‘(V) The percentage and number 

24 of specified requests that were denied, 

25 and the percentage and number of 


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1 specified requests that were approved, 

2 by the plan during the previous plan 

3 year through the utilization of deci4 sion support technology, artificial in5 telligence technology, machine-learn6 ing technology, clinical decision-mak7 ing technology, or any other tech8 nology specified by the Secretary. 

9 ‘‘(VI) The average and the me10 dian amount of time (in hours) that 

11 elapsed during the previous plan year 

12 between the submission of a specified 

13 request to the plan and a determina14 tion by the plan with respect to such 

15 request for each such item and serv16 ice, excluding any such requests that 

17 were not submitted with the medical 

18 or other documentation required to be 

19 submitted by the plan. 

20 ‘‘(VII) The percentage and num21 ber of specified requests that were ex22 cluded from the calculation described 

23 in subclause (VIII) based on the 

24 plan’s determination that such re25 quests were not submitted with the 


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1 medical or other documentation re2 quired to be submitted by the plan. 

3 ‘‘(VIII) Information on each oc4 currence during the previous plan 

5 year in which, during a surgical or 

6 medical procedure involving the fur7 nishing of an applicable item or serv8 ice with respect to which such plan 

9 had approved a prior authorization re10 quest, the provider of services or sup11 plier furnishing such item or service 

12 determined that a different or addi13 tional item or service was medically 

14 necessary, including a specification of 

15 whether such plan subsequently ap16 proved the furnishing of such dif17 ferent or additional item or service. 

18 ‘‘(IX) A disclosure and descrip19 tion of any technology described in 

20 subclause (V) that the plan utilized 

21 during the previous plan year in mak22 ing determinations with respect to 

23 specified requests. 

24 ‘‘(X) The number of grievances 

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1 ceived by such plan during the pre2 vious plan year that were related to a 

3 prior authorization requirement. 

4 ‘‘(XI) Such other information as 

5 the Secretary determines appropriate. 

6 ‘‘(ii) The plan shall provide— 

7 ‘‘(I) to each provider or supplier 

8 who seeks to enter into a contract 

9 with such plan to furnish applicable 

10 items and services under such plan, 

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

12 any policies or procedures used by the 

13 plan for making determinations with 

14 respect to prior authorization re15 quests; 

16 ‘‘(II) to each such provider and 

17 supplier that enters into such a con18 tract, access to the criteria used by 

19 the plan for making such determina20 tions and an itemization of the med21 ical or other documentation required 

22 to be submitted by a provider or sup23 plier with respect to such a request; 

24 and 


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

2 upon request, access to the criteria 

3 used by the plan for making deter4 minations with respect to prior au5 thorization requests for an item or 

6 service. 

7 ‘‘(B) OPTION FOR PLAN TO PROVIDE CER8 TAIN ADDITIONAL INFORMATION.—As part of 

9 the information described in subparagraph 

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

11 year, a Medicare Advantage plan may elect to 

12 include information regarding the percentage 

13 and number of specified requests made with re14 spect to an individual and an item or service 

15 that were denied by the plan during the pre16 ceding plan year in an initial determination 

17 based on such requests failing to demonstrate 

18 that such individuals met the clinical criteria 

19 established by such plan to receive such items 

20 or services. 

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

22 through notice and comment rulemaking, estab23 lish requirements for Medicare Advantage plans 

24 regarding the provision of— 


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1 ‘‘(i) access to criteria described in 

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

3 services and suppliers in accordance with 

4 such subparagraph; and 

5 ‘‘(ii) access to such criteria to enroll6 ees in accordance with subparagraph 

7 (A)(ii)(III). 

8 ‘‘(D) PUBLICATION OF INFORMATION.— 

9 The Secretary shall publish information de10 scribed in subparagraph (A)(i) and subpara11 graph (B) on a public website of the Centers 

12 for Medicare & Medicaid Services. Such infor13 mation shall be so published on an individual 

14 plan level and may in addition be aggregated in 

15 such manner as determined appropriate by the 

16 Secretary. 

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

18 years after the date information is first sub19 mitted under subparagraph (A)(i), the Medicare 

20 Payment Advisory Commission shall submit to 

21 Congress a report on such information that in22 cludes a descriptive analysis of the use of prior 

23 authorization. As appropriate, the Commission 

24 should report on statistics including the fre25 quency of appeals and overturned decisions. 


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1 The Commission shall provide recommenda2 tions, as appropriate, on any improvement that 

3 should be made to the electronic prior author4 ization programs of Medicare Advantage plans. 

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

6 purposes of this paragraph, the term ‘specified 

7 request’ means a prior authorization request 

8 made with respect to an applicable item or serv9 ice. 

10 ‘‘(4) ENROLLEE PROTECTION STANDARDS.— 

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

12 to the use of prior authorization by Medicare Advan13 tage plans for applicable items and services, the en14 rollee protection standards specified in this para15 graph are— 

16 ‘‘(A) the adoption of transparent prior au17 thorization programs developed in consultation 

18 with enrollees and with providers and suppliers 

19 with contracts in effect with such plans for fur20 nishing such items and services under such 

21 plans; 

22 ‘‘(B) allowing for the waiver or modifica23 tion of prior authorization requirements based 

24 on the performance of such providers and sup25 pliers in demonstrating compliance with such 


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1 requirements, such as adherence to evidence2 based medical guidelines and other quality cri3 teria; and 

4 ‘‘(C) conducting annual reviews of such 

5 items and services for which prior authorization 

6 requirements are imposed under such plans 

7 through a process that takes into account input 

8 from enrollees and from providers and suppliers 

9 with such contracts in effect and is based on 

10 consideration of prior authorization data from 

11 previous plan years and analyses of current cov12 erage criteria. 

13 ‘‘(5) APPLICABLE ITEM OR SERVICE DE14 FINED.—For purposes of this subsection, the term 

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

16 Medicare Advantage plan, any item or service for 

17 which benefits are available under such plan, other 

18 than a covered part D drug. 

19 ‘‘(6) REPORTS TO CONGRESS.— 

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

21 2032, the Comptroller General of the United 

22 States shall submit to Congress a report con23 taining an evaluation of the implementation of 

24 the requirements of this subsection and an 


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1 analysis of issues in implementing such require2 ments faced by Medicare Advantage plans. 

3 ‘‘(B) HHS.— 

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

5 the end of the fifth plan year beginning 

6 after the date of the enactment of this sub7 section, and biennially thereafter through 

8 the date that is 10 years after such date 

9 of enactment, the Secretary shall submit to 

10 Congress a report containing a description 

11 of the information submitted under para12 graph (3)(A)(i) during— 

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

14 report, the fourth plan year beginning 

15 after the date of the enactment of this 

16 subsection; and 

17 ‘‘(II) in the case of a subsequent 

18 report, the 2 plan years preceding the 

19 year of the submission of such report. 

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

21 1, 2027, the Centers for Medicare & Med22 icaid Services and the Office of National 

23 Coordinator for Health Information Tech24 nology shall submit to Congress and pub25 lish on the Internet website of the Centers 


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1 for Medicare & Medicaid Services a report 

2 that— 

3 ‘‘(I) defines the term ‘real-time 

4 decision’ and details how the defini5 tion for such term may be updated 

6 based on any technological advances; 

7 ‘‘(II) using the data submitted to 

8 the Secretary under paragraph 

9 (3)(A)(i), details a process for real10 time decisions for items and services 

11 for routinely approved services for 

12 purposes of the electronic prior au13 thorization program described in 

14 paragraph (2); and 

15 ‘‘(III) includes an analysis of— 

16 ‘‘(aa) items and services 

17 that are routinely approved; 

18 ‘‘(bb) items and services 

19 identified in item (aa) that could 

20 be eligible for real-time decisions; 

21 ‘‘(cc) how establishing real22 time decisions for such items and 

23 services could— 


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1 ‘‘(AA) improve enrollee 

2 access to benefits under this 

3 part; 

4 ‘‘(BB) produce oper5 ational efficiencies for pro6 viders of services and sup7 pliers and Medicare Advan8 tage plans; and 

9 ‘‘(CC) reduce health 

10 disparities for Medicare Ad11 vantage enrollees in rural 

12 and low-income commu13 nities; and 

14 ‘‘(dd) how the use of auto15 mated decision-making and artifi16 cial intelligence by Medicare Ad17 vantage plans impact patient ac18 cess, including disparities in ac19 cess for rural and low-income 

20 beneficiaries, to routinely ap21 proved items and services.’’. 

22 (b) PROVIDING THE SECRETARY AUTHORITY TO EN23 FORCE TIMELY RESPONSES FOR ALL PRIOR AUTHORIZA24 TION REQUESTS SUBMITTED UNDER PART C.—Section 


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1 1852(g) of the Social Security Act (42 U.S.C. 1395w– 

2 22(g)) is amended— 

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

4 accordance with any timeframe established by the 

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

6 (3)’’; 

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

8 subject to subsection (o), with respect to prior au9 thorization requests submitted on or after the first 

10 day of the third plan year beginning after the date 

11 of the enactment of the Improving Seniors’ Timely 

12 Access to Care Act of 2024, any timeframe estab13 lished by the Secretary under paragraph (6))’’ after 

14 ‘‘72 hours’’; and 

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

16 paragraph: 

17 ‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU18 THORIZATION REQUESTS.—Subject to paragraph (3) 

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

20 purposes of an organization determination made 

21 with respect to a prior authorization request for an 

22 item or service to be furnished to an individual, 

23 timeframes, such as 24 hours, for the organization 

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

25 appropriate) of such determination for— 


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1 ‘‘(A) a request for expedited determination 

2 described in paragraph (3)(A); 

3 ‘‘(B) a real time decision for routinely ap4 proved items and services; and 

5 ‘‘(C) any other prior authorization re6 quest.’’. 

Æ 


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