I 

118TH CONGRESS 

2D SESSION H. R. 8702 

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 HOUSE OF REPRESENTATIVES 

JUNE 12, 2024 

Mr. KELLY of Pennsylvania (for himself, Ms. DELBENE, Mr. BUCSHON, Mr. 

BERA, Mr. SMITH of Nebraska, Mr. PASCRELL, Mr. PFLUGER, Ms. 

CRAIG, Mr. MOORE of Utah, Mr. KILDEE, Mr. LATTA, Ms. DEGETTE, 

Ms. VAN DUYNE, Mr. SCHNEIDER, Mr. CARTER of Georgia, Ms. MATSUI, 

Mr. WENSTRUP, Mr. BEYER, Mr. CRENSHAW, Mr. SARBANES, Mr. 

FITZPATRICK, Ms. MOORE of Wisconsin, Mrs. HARSHBARGER, Ms. 

BLUNT ROCHESTER, Mrs. MILLER of West Virginia, Mr. GOMEZ, Mr. 

PENCE, Mrs. TRAHAN, Ms. TENNEY, Mr. EVANS, Mr. BILIRAKIS, Ms. 

BARRAGA ́N, Mr. LAHOOD, Mr. PANETTA, Mr. JAMES, Ms. CLARKE of 

New York, Mr. SCHWEIKERT, Mr. LARSON of Connecticut, Mrs. MILLERMEEKS, Mr. FERGUSON, Ms. CHU, Mr. BURGESS, Mr. MURPHY, Ms. 

SA ́NCHEZ, Mr. JOYCE of Pennsylvania, Mr. STEUBE, Ms. SEWELL, Mr. 

DUNN of Florida, Mrs. FISCHBACH, Mr. BLUMENAUER, Mr. HUDSON, 

Mrs. STEEL, Mr. CAREY, Mr. WALBERG, Ms. MALLIOTAKIS, Mr. 

BALDERSON, Mr. ESTES, Mr. SMUCKER, Mr. SMITH of Washington, Mr. 

CARSON, Ms. SALINAS, Mr. HARRIS, Mr. AUSTIN SCOTT of Georgia, Ms. 

PRESSLEY, Mr. LOUDERMILK, Ms. MCCOLLUM, Mr. FOSTER, Mr. 

ALLRED, Ms. BUSH, Mr. MEUSER, Mr. NEWHOUSE, Mr. ROUZER, Ms. 

WASSERMAN SCHULTZ, Ms. ROSS, Mr. KILMER, Ms. TITUS, Mr. BACON, 

Mr. DAVIS of North Carolina, Mr. RUPPERSBERGER, Mr. CASE, Ms. 

NORTON, Mr. MRVAN, Mr. THOMPSON of Pennsylvania, Ms. MENG, Mr. 

STANTON, Mr. RESCHENTHALER, Ms. STEVENS, Mr. LATURNER, Mr. 

RASKIN, Mr. CROW, Mr. JACKSON of North Carolina, Mr. VAN DREW, 

Mrs. KIGGANS of Virginia, Ms. MCCLELLAN, Mr. NADLER, Ms. TOKUDA, 

Mr. BANKS, Mr. COSTA, Mr. MOOLENAAR, Mr. RUTHERFORD, Ms. 

LETLOW, Ms. LOIS FRANKEL of Florida, Ms. DEAN of Pennsylvania, Ms. 

STANSBURY, Mr. BOST, Mr. QUIGLEY, Ms. WILLIAMS of Georgia, Mr. 

KRISHNAMOORTHI, Mr. GRIJALVA, Mr. LARSEN of Washington, Mr. 

TORRES of New York, Mr. MOULTON, Ms. DAVIDS of Kansas, Mr. 

LYNCH, Mr. COHEN, Ms. WILD, Ms. BONAMICI, Mr. LIEU, Ms. LEGER

FERNANDEZ, Mr. SUOZZI, Ms. CARAVEO, Mr. NUNN of Iowa, Mr. HIMES, 

Mr. BURCHETT, Mrs. FOUSHEE, Mr. MANN, Mr. KIM of New Jersey, Mr. 


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FLOOD, Mr. EDWARDS, and Ms. SCHRIER) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

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’’. 

6 SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO 

7 THE USE OF PRIOR AUTHORIZATION UNDER 

8 MEDICARE ADVANTAGE PLANS. 

9 (a) IN GENERAL.—Section 1852 of the Social Secu10 rity Act (42 U.S.C. 1395w–22) is amended by adding at 

11 the end the following new subsection: 

12 ‘‘(o) PRIOR AUTHORIZATION REQUIREMENTS.— 

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

14 Advantage plan that imposes any prior authorization 

15 requirement with respect to any applicable item or 

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

17 year, such plan shall— 


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1 ‘‘(A) beginning with plan years beginning 

2 on or after January 1, 2027— 

3 ‘‘(i) establish the electronic prior au4 thorization program described in para5 graph (2); and 

6 ‘‘(ii) meet the enrollee protection 

7 standards specified pursuant to paragraph 

8 (4); and 

9 ‘‘(B) beginning with plan years beginning 

10 on or after January 1, 2026, meet the trans11 parency requirements specified in paragraph 

12 (3). 

13 ‘‘(2) ELECTRONIC PRIOR AUTHORIZATION PRO14 GRAM.— 

15 ‘‘(A) IN GENERAL.—For purposes of para16 graph (1)(A), the electronic prior authorization 

17 program described in this paragraph is a pro18 gram that provides for the secure electronic 

19 transmission of— 

20 ‘‘(i) a prior authorization request 

21 from a provider of services or supplier to 

22 a Medicare Advantage plan with respect to 

23 an applicable item or service to be fur24 nished to an individual and a response, in 


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1 accordance with this paragraph, from such 

2 plan to such provider or supplier; and 

3 ‘‘(ii) any supporting documentation 

4 relating to such request or response. 

5 ‘‘(B) ELECTRONIC TRANSMISSION.— 

6 ‘‘(i) EXCLUSIONS.—For purposes of 

7 this paragraph, a facsimile, a proprietary 

8 payer portal that does not meet standards 

9 specified by the Secretary, or an electronic 

10 form shall not be treated as an electronic 

11 transmission described in subparagraph 

12 (A). 

13 ‘‘(ii) STANDARDS.—An electronic 

14 transmission described in subparagraph 

15 (A) shall comply with applicable technical 

16 standards and other requirements to pro17 mote the standardization and streamlining 

18 of electronic transactions adopted by the 

19 Secretary. 

20 ‘‘(3) TRANSPARENCY REQUIREMENTS.— 

21 ‘‘(A) IN GENERAL.—For purposes of para22 graph (1)(B), the transparency requirements 

23 specified in this paragraph are, with respect to 

24 a Medicare Advantage plan, the following: 


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1 ‘‘(i) The plan, annually and in a man2 ner specified by the Secretary, shall submit 

3 to the Secretary the following information: 

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

5 and services that were subject to a 

6 prior authorization requirement under 

7 the plan during the previous plan 

8 year. 

9 ‘‘(II) The percentage and number 

10 of specified requests (as defined in 

11 subparagraph (F)) approved during 

12 the previous plan year by the plan in 

13 an initial determination and the per14 centage and number of specified re15 quests denied during such plan year 

16 by such plan in an initial determina17 tion (both in the aggregate and cat18 egorized by each item and service). 

19 ‘‘(III) The percentage and num20 ber of specified requests that were de21 nied during the previous plan year by 

22 the plan in an initial determination 

23 and that were subsequently appealed. 

24 ‘‘(IV) The number of appeals of 

25 specified requests resolved during the 


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1 preceding plan year, and the percent2 age and number of such resolved ap3 peals that resulted in approval of the 

4 furnishing of the item or service that 

5 was the subject of such request, cat6 egorized by each applicable item and 

7 service and categorized by each level 

8 of appeal (including judicial review). 

9 ‘‘(V) The percentage and number 

10 of specified requests that were denied, 

11 and the percentage and number of 

12 specified requests that were approved, 

13 by the plan during the previous plan 

14 year through the utilization of deci15 sion support technology, artificial in16 telligence technology, machine-learn17 ing technology, clinical decision-mak18 ing technology, or any other tech19 nology specified by the Secretary. 

20 ‘‘(VI) The average and the me21 dian amount of time (in hours) that 

22 elapsed during the previous plan year 

23 between the submission of a specified 

24 request to the plan and a determina25 tion by the plan with respect to such 


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1 request for each such item and serv2 ice, excluding any such requests that 

3 were not submitted with the medical 

4 or other documentation required to be 

5 submitted by the plan. 

6 ‘‘(VII) The percentage and num7 ber of specified requests that were ex8 cluded from the calculation described 

9 in subclause (VIII) based on the 

10 plan’s determination that such re11 quests were not submitted with the 

12 medical or other documentation re13 quired to be submitted by the plan. 

14 ‘‘(VIII) Information on each oc15 currence during the previous plan 

16 year in which, during a surgical or 

17 medical procedure involving the fur18 nishing of an applicable item or serv19 ice with respect to which such plan 

20 had approved a prior authorization re21 quest, the provider of services or sup22 plier furnishing such item or service 

23 determined that a different or addi24 tional item or service was medically 

25 necessary, including a specification of 


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1 whether such plan subsequently ap2 proved the furnishing of such dif3 ferent or additional item or service. 

4 ‘‘(IX) A disclosure and descrip5 tion of any technology described in 

6 subclause (V) that the plan utilized 

7 during the previous plan year in mak8 ing determinations with respect to 

9 specified requests. 

10 ‘‘(X) The number of grievances 

11 (as described in subsection (f)) re12 ceived by such plan during the pre13 vious plan year that were related to a 

14 prior authorization requirement. 

15 ‘‘(XI) Such other information as 

16 the Secretary determines appropriate. 

17 ‘‘(ii) The plan shall provide— 

18 ‘‘(I) to each provider or supplier 

19 who seeks to enter into a contract 

20 with such plan to furnish applicable 

21 items and services under such plan, 

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

23 any policies or procedures used by the 

24 plan for making determinations with 


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1 respect to prior authorization re2 quests; 

3 ‘‘(II) to each such provider and 

4 supplier that enters into such a con5 tract, access to the criteria used by 

6 the plan for making such determina7 tions and an itemization of the med8 ical or other documentation required 

9 to be submitted by a provider or sup10 plier with respect to such a request; 

11 and 

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

13 upon request, access to the criteria 

14 used by the plan for making deter15 minations with respect to prior au16 thorization requests for an item or 

17 service. 

18 ‘‘(B) OPTION FOR PLAN TO PROVIDE CER19 TAIN ADDITIONAL INFORMATION.—As part of 

20 the information described in subparagraph 

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

22 year, a Medicare Advantage plan may elect to 

23 include information regarding the percentage 

24 and number of specified requests made with re25 spect to an individual and an item or service 


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1 that were denied by the plan during the pre2 ceding plan year in an initial determination 

3 based on such requests failing to demonstrate 

4 that such individuals met the clinical criteria 

5 established by such plan to receive such items 

6 or services. 

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

8 through notice and comment rulemaking, estab9 lish requirements for Medicare Advantage plans 

10 regarding the provision of— 

11 ‘‘(i) access to criteria described in 

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

13 services and suppliers in accordance with 

14 such subparagraph; and 

15 ‘‘(ii) access to such criteria to enroll16 ees in accordance with subparagraph 

17 (A)(ii)(III). 

18 ‘‘(D) PUBLICATION OF INFORMATION.— 

19 The Secretary shall publish information de20 scribed in subparagraph (A)(i) and subpara21 graph (B) on a public website of the Centers 

22 for Medicare & Medicaid Services. Such infor23 mation shall be so published on an individual 

24 plan level and may in addition be aggregated in 


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1 such manner as determined appropriate by the 

2 Secretary. 

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

4 years after the date information is first sub5 mitted under subparagraph (A)(i), the Medicare 

6 Payment Advisory Commission shall submit to 

7 Congress a report on such information that in8 cludes a descriptive analysis of the use of prior 

9 authorization. As appropriate, the Commission 

10 should report on statistics including the fre11 quency of appeals and overturned decisions. 

12 The Commission shall provide recommenda13 tions, as appropriate, on any improvement that 

14 should be made to the electronic prior author15 ization programs of Medicare Advantage plans. 

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

17 purposes of this paragraph, the term ‘specified 

18 request’ means a prior authorization request 

19 made with respect to an applicable item or serv20 ice. 

21 ‘‘(4) ENROLLEE PROTECTION STANDARDS.— 

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

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1 rollee protection standards specified in this para2 graph are— 

3 ‘‘(A) the adoption of transparent prior au4 thorization programs developed in consultation 

5 with enrollees and with providers and suppliers 

6 with contracts in effect with such plans for fur7 nishing such items and services under such 

8 plans; 

9 ‘‘(B) allowing for the waiver or modifica10 tion of prior authorization requirements based 

11 on the performance of such providers and sup12 pliers in demonstrating compliance with such 

13 requirements, such as adherence to evidence14 based medical guidelines and other quality cri15 teria; and 

16 ‘‘(C) conducting annual reviews of such 

17 items and services for which prior authorization 

18 requirements are imposed under such plans 

19 through a process that takes into account input 

20 from enrollees and from providers and suppliers 

21 with such contracts in effect and is based on 

22 consideration of prior authorization data from 

23 previous plan years and analyses of current cov24 erage criteria. 


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1 ‘‘(5) APPLICABLE ITEM OR SERVICE DE2 FINED.—For purposes of this subsection, the term 

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

4 Medicare Advantage plan, any item or service for 

5 which benefits are available under such plan, other 

6 than a covered part D drug. 

7 ‘‘(6) REPORTS TO CONGRESS.— 

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

9 2028, the Comptroller General of the United 

10 States shall submit to Congress a report con11 taining an evaluation of the implementation of 

12 the requirements of this subsection and an 

13 analysis of issues in implementing such require14 ments faced by Medicare Advantage plans. 

15 ‘‘(B) HHS.— 

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

17 the end of the fifth plan year beginning 

18 after the date of the enactment of this sub19 section, and biennially thereafter through 

20 the date that is 10 years after such date 

21 of enactment, the Secretary shall submit to 

22 Congress a report containing a description 

23 of the information submitted under para24 graph (3)(A)(i) during— 


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

2 report, the fourth plan year beginning 

3 after the date of the enactment of this 

4 subsection; and 

5 ‘‘(II) in the case of a subsequent 

6 report, the 2 plan years preceding the 

7 year of the submission of such report. 

8 ‘‘(ii) CMS.—Not later than January 

9 1, 2027, the Centers for Medicare & Med10 icaid Services and the Office of National 

11 Coordinator for Health Information Tech12 nology shall submit to Congress and pub13 lish on the Internet website of the Centers 

14 for Medicare & Medicaid Services a report 

15 that— 

16 ‘‘(I) defines the term ‘real-time 

17 decision’ and details how the defini18 tion for such term may be updated 

19 based on any technological advances; 

20 ‘‘(II) using the data submitted to 

21 the Secretary under paragraph 

22 (3)(A)(i), details a process for real23 time decisions for items and services 

24 for routinely approved services for 

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1 thorization program described in 

2 paragraph (2); and 

3 ‘‘(III) includes an analysis of— 

4 ‘‘(aa) items and services 

5 that are routinely approved; 

6 ‘‘(bb) items and services 

7 identified in item (aa) that could 

8 be eligible for real-time decisions; 

9 ‘‘(cc) how establishing real10 time decisions for such items and 

11 services could— 

12 ‘‘(AA) improve enrollee 

13 access to benefits under this 

14 part; 

15 ‘‘(BB) produce oper16 ational efficiencies for pro17 viders of services and sup18 pliers and Medicare Advan19 tage plans; and 

20 ‘‘(CC) reduce health 

21 disparities for Medicare Ad22 vantage enrollees in rural 

23 and low-income commu24 nities; and 


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1 ‘‘(dd) how the use of auto2 mated decision-making and artifi3 cial intelligence by Medicare Ad4 vantage plans impact patient ac5 cess, including disparities in ac6 cess for rural and low-income 

7 beneficiaries, to routinely ap8 proved items and services.’’. 

9 (b) PROVIDING THE SECRETARY AUTHORITY TO EN10 FORCE TIMELY RESPONSES FOR ALL PRIOR AUTHORIZA11 TION REQUESTS SUBMITTED UNDER PART C.—Section 

12 1852(g) of the Social Security Act (42 U.S.C. 1395w– 

13 22(g)) is amended— 

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

15 accordance with any timeframe established by the 

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

17 (3)’’; 

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

19 subject to subsection (o), with respect to prior au20 thorization requests submitted on or after the first 

21 day of the third plan year beginning after the date 

22 of the enactment of the Improving Seniors’ Timely 

23 Access to Care Act of 2024, any timeframe estab24 lished by the Secretary under paragraph (6))’’ after 

25 ‘‘72 hours’’; and 


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

2 paragraph: 

3 ‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU4 THORIZATION REQUESTS.—Subject to paragraph (3) 

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

6 purposes of an organization determination made 

7 with respect to a prior authorization request for an 

8 item or service to be furnished to an individual, 

9 timeframes, such as 24 hours, for the organization 

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

11 appropriate) of such determination for— 

12 ‘‘(A) a request for expedited determination 

13 described in paragraph (3)(A); 

14 ‘‘(B) a real time decision for routinely ap15 proved items and services; and 

16 ‘‘(C) any other prior authorization re17 quest.’’. 

Æ 


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