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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4968 Introduced in House (IH)]

<DOC>

118th CONGRESS
  1st Session
                                H. R. 4968

 To amend title XVIII of the Social Security Act to exempt qualifying 
    physicians from prior authorization requirements under Medicare 
                Advantage plans, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             July 27, 2023

Mr. Burgess (for himself and Mr. Vicente Gonzalez of Texas) 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 exempt qualifying 
    physicians from prior authorization requirements under Medicare 
                Advantage plans, and for other purposes.

    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 ``Getting Over Lengthy Delays in Care 
As Required by Doctors Act of 2023'' or the ``GOLD CARD Act of 2023''.

SEC. 2. EXEMPTION FOR QUALIFYING PHYSICIANS FROM PRIOR AUTHORIZATION 
              REQUIREMENTS UNDER MA PLANS.

    (a) In General.--Section 1852 of the Social Security Act (42 U.S.C. 
1395w-22) is amended by adding at the end the following new subsection:
    ``(o) Exemption for Qualifying Physicians From Prior Authorization 
Requirements.--
            ``(1) In general.--
                    ``(A) Exemption.--
                            ``(i) In general.--In the case of an MA 
                        organization which utilizes a prior 
                        authorization process (as defined in 
                        subparagraph (B)) with respect to a plan year 
                        (beginning with the second plan year beginning 
                        after the date of the enactment of this 
                        subsection), subject to the succeeding 
                        provisions of this subsection, a physician 
                        shall be exempt from the prior authorization 
                        requirements under such process for the period 
                        of such plan year with respect to a specific 
                        item, service, or group of similar services, if 
                        during the preceding plan year at least 90 
                        percent of prior authorization requests 
                        submitted to such organization by such 
                        physician for such item, service, or group were 
                        approved by such organization (including any 
                        approval granted after an appeal). Such 
                        exemption shall continue to apply with respect 
                        to such physician furnishing such item, 
                        service, or group of similar services in 
                        subsequent plan years until the earlier of--
                                    ``(I) the date on which such 
                                exemption is revoked under paragraph 
                                (5); or
                                    ``(II) the date on which such 
                                physician opts out of such exemption 
                                under paragraph (3)(C).
                            ``(ii) Special rules.--For purposes of 
                        determining whether a physician qualifies for 
                        an exemption under clause (i) for a plan year 
                        for an item, service, or group of services, in 
                        calculating whether at least 90 percent of 
                        prior authorization requests submitted by such 
                        physician for such item, services, or group 
                        during the preceding plan year were approved, 
                        an MA organization shall--
                                    ``(I) subject to subclause (II), 
                                treat any such claim that was initially 
                                denied, subsequently appealed, and that 
                                remains pending appeal at the time of 
                                such calculation as having been 
                                approved if more than 30 days have 
                                elapsed since the date such appeal was 
                                filed; and
                                    ``(II) in the case that, during 
                                such plan year, such organization 
                                changed any terms of coverage for such 
                                item, service, or group of services, 
                                not take into account any claims for 
                                such item, service, or group of 
                                services that were submitted during the 
                                90-day period beginning on the date of 
                                such change.
                    ``(B) Prior authorization process.--For purposes of 
                this subsection, the term `prior authorization process' 
                means, with respect to coverage and payment for items 
                and services (other than a covered part D drug) under 
                an MA plan offered by an MA organization for a plan 
                year, a process under which such organization (or a 
                contractor of such organization) determines the medical 
                necessity or medical appropriateness of such items and 
                services prior to the furnishing of such items and 
                services or that otherwise requires an individual 
                enrolled under such plan, or a provider of services or 
                supplier scheduled to furnish items and services to 
                such individual, to notify such plan (or such 
                contractor) prior to such individual receiving such 
                items and services.
            ``(2) Frequency of determination of eligibility for 
        exemption.--An MA organization may not evaluate a physician for 
        the exemption described in paragraph (1) more than once during 
        any plan year.
            ``(3) Notification requirements.--
                    ``(A) Qualification.--An MA organization shall, not 
                later than 30 days before the first day of each plan 
                year, notify each physician who qualifies for the 
                exemption described in paragraph (1) of such 
                qualification and the items, services, or group of 
                similar services with respect to which such exemption 
                applies for such physician. Nothing in this 
                subparagraph shall preclude an MA organization from 
                notifying a physician of such exemption at additional 
                times throughout a plan year.
                    ``(B) Requests under exemption.--In the case of a 
                physician described in subparagraph (A) who submits a 
                prior authorization request to an MA organization for 
                an item or service with respect to which an exemption 
                applies under this subsection, such organization shall 
                notify such physician of such exemption as soon as 
                possible (but in no case later than 24 hours after 
                receiving such request).
                    ``(C) Opt out.--Any physician eligible for an 
                exemption under paragraph (1) may voluntarily waive 
                such exemption by providing written notice to the 
                applicable MA organization.
            ``(4) Requirement for coverage and payment.--In the case of 
        a physician who qualifies for the exemption described in 
        paragraph (1) with respect to an item, service, or group of 
        similar services, an MA organization may not deny or reduce 
        coverage and payment for such an item, service, or group based 
        on medical necessity or appropriateness of care.
            ``(5) Protections pertaining to revocation of gold card.--
                    ``(A) In general.--An MA organization may revoke an 
                exemption described in paragraph (1) granted with 
                respect to a physician for an item, service, or group 
                of similar services for a plan year only if--
                            ``(i) the MA organization--
                                    ``(I) determines that--
                                            ``(aa) less than 90 percent 
                                        of claims submitted by such 
                                        physician for such item, 
                                        service, or group during the 
                                        90-day period ending on the 
                                        date of such revocation would 
                                        have been approved under the 
                                        prior authorization process 
                                        employed by such plan had such 
                                        process applied with respect to 
                                        such claims; or
                                            ``(bb) in the case that 
                                        fewer than 10 claims were 
                                        submitted by such physician for 
                                        such item, service, or group 
                                        during the 90-day period ending 
                                        on the date of such revocation, 
                                        less than 90 percent of the 
                                        last 10 claims submitted by 
                                        such physician for such item, 
                                        service, or group as of the 
                                        date of such revocation would 
                                        have been so approved;
                                    ``(II) furnishes such physician 
                                with a notice of such revocation 
                                containing the claim information 
                                (including identification of specific 
                                items and services and the individual 
                                to whom such items and services were 
                                furnished) on which the determination 
                                under subclause (I) was made; and
                                    ``(III) includes in such notice a 
                                plain-language description of how such 
                                physician may appeal such determination 
                                in accordance with the rules 
                                promulgated under subparagraph (B); and
                            ``(ii) the individual conducting the 
                        determination under clause (ii)(I)--
                                    ``(I) is a physician;
                                    ``(II) possesses a current and 
                                nonrestricted license to practice 
                                medicine in the State in which the 
                                items, services, or group of services 
                                to which such exemption applies were 
                                furnished;
                                    ``(III) is actively engaged in the 
                                practice of medicine in the same or 
                                similar specialty as a physician that 
                                would typically furnish such item, 
                                service, or group of services; and
                                    ``(IV) is knowledgeable about the 
                                furnishing of, and has experience 
                                furnishing, such item, service, or 
                                group of services.
                    ``(B) Appeal of exemption.--The Secretary shall, 
                through notice and comment rulemaking, establish a 
                process under which a physician may appeal a revocation 
                under subparagraph (A). Such process shall ensure that 
                any such appeal is resolved within 30 days of such 
                appeal being submitted under such process.
                    ``(C) Treatment of unresolved claims.--The 
                provisions of paragraph (1)(A)(ii) shall apply with 
                respect to the treatment of claims for a determination 
                made under subparagraph (A) in the same manner as such 
                provisions apply with respect to the treatment of 
                claims for a determination made under paragraph 
                (1)(A).''.
    (b) Rulemaking.--The Secretary of Health and Human Services shall, 
through rulemaking, specify requirements with respect to the use of 
prior authorization by Medicare Advantage plans for items and services 
described in subsection (o)(1) of section 1852 of the Social Security 
Act (42 U.S.C. 1395w-22), as added by subsection (a), to ensure 
continuity of care for individuals transitioning to, or between, 
coverage under such plans in order to minimize any disruption to 
ongoing treatment attributable to prior authorization requirements 
under such plans.
    (c) Report.--Not later than 2 years after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall submit to 
Congress a report on the potential impacts of the amendment made by 
this section on communities at high risk for health disparities.

SEC. 3. OPPORTUNITY FOR PROVIDERS TO PRESENT CASES FOR COVERAGE AND 
              PAYMENT DURING THE PRIOR AUTHORIZATION PROCESS UNDER MA 
              PLANS.

    Section 1852 of the Social Security Act (42 U.S.C. 1395w-22), as 
amended by section 2, is further amended by adding at the end the 
following new subsection:
    ``(p) Opportunity for Providers To Present Cases for Coverage and 
Payment During the Prior Authorization Process.--
            ``(1) In general.--For plan years beginning with the second 
        plan year beginning after the date of the enactment of this 
        subsection, any prior authorization process (as defined in 
        subsection (o)(1)(B)) with respect to the coverage and payment 
        for items and services (other than a covered part D drug) under 
        an MA plan offered by an MA organization shall provide, prior 
        to any coverage or payment determination with respect to an 
        item or service subject to such process, for an opportunity for 
        a provider of services or supplier seeking prior authorization 
        to furnish such item or service to discuss with a qualifying 
        physician (as defined in paragraph (2))--
                    ``(A) the treatment plan for the individual who 
                would be furnished such item or service; and
                    ``(B) the clinical basis on which the organization 
                will determine coverage or payment for such item or 
                service.
            ``(2) Qualifying physician defined.--For purposes of 
        paragraph (1), the term `qualifying physician' means, with 
        respect to an item or service subject to a process described in 
        such paragraph that a provider of services or supplier is 
        seeking to furnish to an individual, a physician that--
                    ``(A) possesses a current and nonrestricted license 
                to practice medicine in the State in which such item or 
                service is to be furnished;
                    ``(B) is actively engaged in the practice of 
                medicine in the same or similar specialty as a provider 
                of services or supplier that would typically furnish 
                such item or service; and
                    ``(C) is knowledgeable about the furnishing of, and 
                has experience furnishing, such item or service.''.
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