I 

116TH CONGRESS 

1ST SESSION H. R. 3107 

To amend title XVIII of the Social Security Act to establish requirements 

with respect to the use of prior authorization under Medicare Advantage 

plans, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 5, 2019 

Ms. DELBENE (for herself, Mr. KELLY of Pennsylvania, Mr. MARSHALL, and 

Mr. BERA) 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, and for other purposes. 

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 2019’’. 


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1 SEC. 2. SENSE OF CONGRESS. 

2 It is the sense of Congress that— 

3 (1) use of prior authorization should be stream4 lined through electronic transmissions for coverage 

5 of covered services for individuals enrolled in feder6 ally funded programs such as Medicare, Medicaid, 

7 and federally contracted managed care plans to im8 prove patient access to medically appropriate serv9 ices and reduce administrative burden through auto10 mation informed by clinical decision support; 

11 (2) there should be increased transparency for 

12 beneficiaries and providers and increased oversight 

13 by the Centers for Medicare & Medicaid Services on 

14 the processes used for prior authorization; and 

15 (3) prior authorization is a tool that can be 

16 used to responsibly prevent unnecessary care and 

17 promote safe and evidence-based care. 

18 SEC. 3. ESTABLISHING REQUIREMENTS WITH RESPECT TO 

19 THE USE OF PRIOR AUTHORIZATION UNDER 

20 MEDICARE ADVANTAGE PLANS. 

21 (a) IN GENERAL.—Section 1852 of the Social Secu22 rity Act (42 U.S.C. 1395w–22) is amended by adding at 

23 the end the following new subsection: 

24 ‘‘(o) PRIOR AUTHORIZATION REQUIREMENTS.— 

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

26 Advantage plan that imposes any prior authorization 


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1 requirement with respect to any benefit, such plan 

2 shall, beginning with the first plan year beginning 

3 on or after the date of the enactment of this sub4 section— 

5 ‘‘(A) comply with the prohibition described 

6 in paragraph (2); 

7 ‘‘(B) establish the electronic prior author8 ization program described in paragraph (3); 

9 ‘‘(C) meet the transparency requirements 

10 specified in paragraph (4); and 

11 ‘‘(D) meet the beneficiary protection stand12 ards specified pursuant to paragraph (5). 

13 ‘‘(2) PROHIBITION ON PRIOR AUTHORIZATION

14 WITH RESPECT TO CERTAIN ITEMS AND SERVICES.— 

15 A Medicare Advantage plan may not impose any ad16 ditional prior authorization requirement with respect 

17 to any surgical procedure or otherwise invasive pro18 cedure (as defined by the Secretary), and any item 

19 furnished as part of such surgical or invasive proce20 dure, if such procedure (or item) is furnished during 

21 the peroperative period of a procedure for which— 

22 ‘‘(A) prior authorization was received from 

23 such plan before such surgical or otherwise 

24 invasive procedure (or item furnished as part of 


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1 such surgical or otherwise invasive procedure) 

2 was furnished; or 

3 ‘‘(B) prior authorization was not required 

4 by such plan. 

5 ‘‘(3) ELECTRONIC PRIOR AUTHORIZATION PRO6 GRAM.— 

7 ‘‘(A) IN GENERAL.—For purposes of para8 graph (1)(B), the electronic prior authorization 

9 program described in this paragraph is a prior 

10 authorization process implemented by a Medi11 care Advantage plan that provides for the se12 cure electronic transmission of— 

13 ‘‘(i) a prior authorization request 

14 from a health care professional to such 

15 plan with respect to an item or service to 

16 be furnished to an individual, including 

17 such clinical information as the profes18 sional determines appropriate to support 

19 the furnishing of such item or service to 

20 such individual; and 

21 ‘‘(ii) a response, in accordance with 

22 this paragraph, from such plan to such 

23 professional. 

24 ‘‘(B) ELECTRONIC TRANSMISSION.— 


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1 ‘‘(i) EXCLUSIONS.—For purposes of 

2 this paragraph, a facsimile, a proprietary 

3 payer portal that does not meet standards 

4 specified by the Secretary, or an electronic 

5 form shall not be treated as an electronic 

6 transmission described in subparagraph 

7 (A). 

8 ‘‘(ii) STANDARDS.— 

9 ‘‘(I) IN GENERAL.—In order to 

10 ensure appropriate clinical outcome 

11 for individuals, for purposes of this 

12 paragraph, an electronic transmission 

13 described in subparagraph (A) shall 

14 comply with technical standards 

15 adopted by the Secretary in consulta16 tion with standard-setting organiza17 tions determined appropriate by the 

18 Secretary, health care professionals, 

19 MA organizations, and health infor20 mation technology software vendors. 

21 In adopting such standards, the Sec22 retary shall ensure that such trans23 missions support attachments con24 taining applicable clinical information 

25 and shall prioritize the adoption of 


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1 standards that encourage integration 

2 of the electronic prior authorization 

3 program into established electronic 

4 health record systems. 

5 ‘‘(II) TRANSACTION STAND6 ARD.—The Secretary shall include in 

7 the standards adopted under sub8 clause (I) a standard with respect to 

9 the transmission of attachments de10 scribed in such subclause, and data 

11 elements and operating rules for such 

12 transmission, consistent with health 

13 care industry standards. 

14 ‘‘(C) REAL-TIME DECISIONS.— 

15 ‘‘(i) IN GENERAL.—The program de16 scribed in subparagraph (A) shall provide 

17 for real-time decisions (as defined by the 

18 Secretary) with respect to requests identi19 fied by the Secretary pursuant to clause 

20 (ii) for a plan year if such requests contain 

21 all information required by an MA plan to 

22 evaluate the criteria described in para23 graph (4)(A)(iii)(II). 

24 ‘‘(ii) IDENTIFICATION OF RE25 QUESTS.—For purposes of clause (i) and 


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1 with respect to a plan year, the Secretary 

2 shall identify, not later than the date on 

3 which the initial announcement described 

4 in section 1853(b)(1)(B)(i) for such plan 

5 year is required to be announced, items 

6 and services for which prior authorization 

7 requests are routinely approved. 

8 ‘‘(iii) DATA COLLECTION AND CON9 SULTATION WITH RELEVANT ELIGIBLE

10 PROFESSIONAL ORGANIZATIONS AND REL11 EVANT STAKEHOLDERS.—In identifying re12 quests for a year under clause (ii), the Sec13 retary shall use the information described 

14 in paragraph (4)(A) (if available) and shall 

15 issue a request for information from pro16 viders, suppliers, patient advocacy organi17 zations, and other stakeholders. 

18 ‘‘(4) TRANSPARENCY REQUIREMENTS.— 

19 ‘‘(A) IN GENERAL.—For purposes of para20 graph (1)(C), the transparency requirements 

21 specified in this paragraph are, with respect to 

22 a Medicare Advantage plan, the following: 

23 ‘‘(i) The plan, not less frequently than 

24 annually and at a time and in a manner 


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1 specified by the Secretary, shall submit to 

2 the Secretary the following information: 

3 ‘‘(I) A list of all items and serv4 ices that are described in subsection 

5 (a)(1)(B) that are subject to a prior 

6 authorization requirement under the 

7 plan. 

8 ‘‘(II) The percentage of prior au9 thorization requests approved during 

10 the previous plan year by the plan 

11 with respect to each such item and 

12 service. 

13 ‘‘(III) The percentage of such re14 quests that were initially denied and 

15 that were subsequently appealed, and 

16 the percentage of such appealed re17 quests that were overturned, with re18 spect to each such item and service. 

19 ‘‘(IV) The average and the me20 dian amount of time (in hours) that 

21 elapsed during the previous plan year 

22 between the submission of such a re23 quest to the plan and a determination 

24 by the plan with respect to such re25 quest for each such item and service, 


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1 excluding any such requests that did 

2 not contain all information required to 

3 be submitted by the plan. 

4 ‘‘(V) Such other information as 

5 the Secretary determines appropriate 

6 after consultation with and comment 

7 from stakeholders. 

8 ‘‘(ii) The plan shall publish the infor9 mation described in clause (i) annually be10 fore open enrollment on a publicly available 

11 website. Such plan shall provide the ad12 dress of such website in any enrollment 

13 materials distributed by the plan and shall 

14 update such website in a timely manner. 

15 ‘‘(iii) The plan shall provide— 

16 ‘‘(I) along with contract mate17 rials for any provider or supplier who 

18 seeks to participate under the plan, 

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

20 any policies or procedures used by the 

21 plan for making determinations with 

22 respect to prior authorization re23 quests; and 

24 ‘‘(II) to each provider and sup25 plier participating under the plan, acVerDate Sep 11 2014 04:42 Jun 14, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3107.IH H3107

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1 cess to the criteria used by the plan 

2 for making such determinations, in3 cluding an itemization of the medical 

4 or other documentation required to be 

5 submitted by a provider or supplier 

6 with respect to such a request, except 

7 to the extent that provision of access 

8 to such criteria would disclose propri9 etary information of such plan, as de10 termined by the Secretary. 

11 ‘‘(B) REPORT TO CONGRESS.—Not later 

12 than the end of the second plan year beginning 

13 on or after the date of the enactment of this 

14 subsection, and biennially thereafter, the Sec15 retary shall submit to Congress a report de16 scribing the information submitted under sub17 paragraph (A)(i) with respect to— 

18 ‘‘(i) in the case of the first such re19 port, the first plan year beginning on or 

20 after such date; and 

21 ‘‘(ii) in the case of a subsequent re22 port, the 2 full plan years preceding the 

23 date of the submission of such report. 

24 ‘‘(5) BENEFICIARY PROTECTION STANDARDS.— 

25 The Secretary of Health and Human Services shall, 


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1 through notice and comment rulemaking, specify 

2 standards with respect to the use of prior authoriza3 tion by MA plans to ensure— 

4 ‘‘(A) that such plans adopt transparent 

5 programs developed in consultation with pro6 viders and suppliers participating under the 

7 plans that promote the modification of such re8 quirements based on the performance of such 

9 providers and suppliers with respect to adher10 ence to evidence-based medical guidelines and 

11 other quality criteria; 

12 ‘‘(B) that such plans conduct annual re13 views of items and services for which prior au14 thorization requirements are imposed under 

15 such plans through a process that takes into ac16 count input from participating providers and 

17 suppliers and is based on analysis of past prior 

18 authorization requests and current clinical cri19 teria; 

20 ‘‘(C) continuity of care for individuals 

21 transitioning to, or between, coverage under 

22 such plans in order to minimize any disruption 

23 to ongoing treatment attributable to prior au24 thorization requirements under such plans; 


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1 ‘‘(D) that such plans make timely prior au2 thorization determinations, provide rationales 

3 for denials, and ensure requests are reviewed by 

4 qualified medical personnel; and 

5 ‘‘(E) that plans assist providers and sup6 pliers in submitting the information necessary 

7 to enable the plan to make a prior authorization 

8 determination in a timely manner.’’. 

9 (b) DETERMINATION CLARIFICATION.—Section 

10 1852(g)(1)(A) of the Social Security Act (42 U.S.C. 

11 1392w–22(g)(1)(A)) is amended by inserting ‘‘(including 

12 any decision made with respect to a prior authorization 

13 request for such service)’’ after ‘‘section’’. 

Æ 


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