I 

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. 

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 ‘‘Getting Over Lengthy 

5 Delays in Care As Required by Doctors Act of 2023’’ or 

6 the ‘‘GOLD CARD Act of 2023’’. 


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1 SEC. 2. EXEMPTION FOR QUALIFYING PHYSICIANS FROM 

2 PRIOR AUTHORIZATION REQUIREMENTS 

3 UNDER MA 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) EXEMPTION FOR QUALIFYING PHYSICIANS

8 FROM PRIOR AUTHORIZATION REQUIREMENTS.— 

9 ‘‘(1) IN GENERAL.— 

10 ‘‘(A) EXEMPTION.— 

11 ‘‘(i) IN GENERAL.—In the case of an 

12 MA organization which utilizes a prior au13 thorization process (as defined in subpara14 graph (B)) with respect to a plan year (be15 ginning with the second plan year begin16 ning after the date of the enactment of 

17 this subsection), subject to the succeeding 

18 provisions of this subsection, a physician 

19 shall be exempt from the prior authoriza20 tion requirements under such process for 

21 the period of such plan year with respect 

22 to a specific item, service, or group of simi23 lar services, if during the preceding plan 

24 year at least 90 percent of prior authoriza25 tion requests submitted to such organiza26 tion by such physician for such item, servVerDate Sep 11 2014 03:36 Aug 15, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4968.IH H4968

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1 ice, or group were approved by such orga2 nization (including any approval granted 

3 after an appeal). Such exemption shall con4 tinue to apply with respect to such physi5 cian furnishing such item, service, or group 

6 of similar services in subsequent plan years 

7 until the earlier of— 

8 ‘‘(I) the date on which such ex9 emption is revoked under paragraph 

10 (5); or 

11 ‘‘(II) the date on which such phy12 sician opts out of such exemption 

13 under paragraph (3)(C). 

14 ‘‘(ii) SPECIAL RULES.—For purposes 

15 of determining whether a physician quali16 fies for an exemption under clause (i) for 

17 a plan year for an item, service, or group 

18 of services, in calculating whether at least 

19 90 percent of prior authorization requests 

20 submitted by such physician for such item, 

21 services, or group during the preceding 

22 plan year were approved, an MA organiza23 tion shall— 

24 ‘‘(I) subject to subclause (II), 

25 treat any such claim that was initially 


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1 denied, subsequently appealed, and 

2 that remains pending appeal at the 

3 time of such calculation as having 

4 been approved if more than 30 days 

5 have elapsed since the date such ap6 peal was filed; and 

7 ‘‘(II) in the case that, during 

8 such plan year, such organization 

9 changed any terms of coverage for 

10 such item, service, or group of serv11 ices, not take into account any claims 

12 for such item, service, or group of 

13 services that were submitted during 

14 the 90-day period beginning on the 

15 date of such change. 

16 ‘‘(B) PRIOR AUTHORIZATION PROCESS.— 

17 For purposes of this subsection, the term ‘prior 

18 authorization process’ means, with respect to 

19 coverage and payment for items and services 

20 (other than a covered part D drug) under an 

21 MA plan offered by an MA organization for a 

22 plan year, a process under which such organiza23 tion (or a contractor of such organization) de24 termines the medical necessity or medical ap25 propriateness of such items and services prior 


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1 to the furnishing of such items and services or 

2 that otherwise requires an individual enrolled 

3 under such plan, or a provider of services or 

4 supplier scheduled to furnish items and services 

5 to such individual, to notify such plan (or such 

6 contractor) prior to such individual receiving 

7 such items and services. 

8 ‘‘(2) FREQUENCY OF DETERMINATION OF ELI9 GIBILITY FOR EXEMPTION.—An MA organization 

10 may not evaluate a physician for the exemption de11 scribed in paragraph (1) more than once during any 

12 plan year. 

13 ‘‘(3) NOTIFICATION REQUIREMENTS.— 

14 ‘‘(A) QUALIFICATION.—An MA organiza15 tion shall, not later than 30 days before the 

16 first day of each plan year, notify each physi17 cian who qualifies for the exemption described 

18 in paragraph (1) of such qualification and the 

19 items, services, or group of similar services with 

20 respect to which such exemption applies for 

21 such physician. Nothing in this subparagraph 

22 shall preclude an MA organization from noti23 fying a physician of such exemption at addi24 tional times throughout a plan year. 


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1 ‘‘(B) REQUESTS UNDER EXEMPTION.—In 

2 the case of a physician described in subpara3 graph (A) who submits a prior authorization re4 quest to an MA organization for an item or 

5 service with respect to which an exemption ap6 plies under this subsection, such organization 

7 shall notify such physician of such exemption as 

8 soon as possible (but in no case later than 24 

9 hours after receiving such request). 

10 ‘‘(C) OPT OUT.—Any physician eligible for 

11 an exemption under paragraph (1) may volun12 tarily waive such exemption by providing writ13 ten notice to the applicable MA organization. 

14 ‘‘(4) REQUIREMENT FOR COVERAGE AND PAY15 MENT.—In the case of a physician who qualifies for 

16 the exemption described in paragraph (1) with re17 spect to an item, service, or group of similar serv18 ices, an MA organization may not deny or reduce 

19 coverage and payment for such an item, service, or 

20 group based on medical necessity or appropriateness 

21 of care. 

22 ‘‘(5) PROTECTIONS PERTAINING TO REVOCA23 TION OF GOLD CARD.— 

24 ‘‘(A) IN GENERAL.—An MA organization 

25 may revoke an exemption described in paraVerDate Sep 11 2014 03:36 Aug 15, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4968.IH H4968

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1 graph (1) granted with respect to a physician 

2 for an item, service, or group of similar services 

3 for a plan year only if— 

4 ‘‘(i) the MA organization— 

5 ‘‘(I) determines that— 

6 ‘‘(aa) less than 90 percent 

7 of claims submitted by such phy8 sician for such item, service, or 

9 group during the 90-day period 

10 ending on the date of such rev11 ocation would have been ap12 proved under the prior authoriza13 tion process employed by such 

14 plan had such process applied 

15 with respect to such claims; or 

16 ‘‘(bb) in the case that fewer 

17 than 10 claims were submitted 

18 by such physician for such item, 

19 service, or group during the 90- 

20 day period ending on the date of 

21 such revocation, less than 90 per22 cent of the last 10 claims sub23 mitted by such physician for such 

24 item, service, or group as of the 


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1 date of such revocation would 

2 have been so approved; 

3 ‘‘(II) furnishes such physician 

4 with a notice of such revocation con5 taining the claim information (includ6 ing identification of specific items and 

7 services and the individual to whom 

8 such items and services were fur9 nished) on which the determination 

10 under subclause (I) was made; and 

11 ‘‘(III) includes in such notice a 

12 plain-language description of how 

13 such physician may appeal such deter14 mination in accordance with the rules 

15 promulgated under subparagraph (B); 

16 and 

17 ‘‘(ii) the individual conducting the de18 termination under clause (ii)(I)— 

19 ‘‘(I) is a physician; 

20 ‘‘(II) possesses a current and 

21 nonrestricted license to practice medi22 cine in the State in which the items, 

23 services, or group of services to which 

24 such exemption applies were fur25 nished; 


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1 ‘‘(III) is actively engaged in the 

2 practice of medicine in the same or 

3 similar specialty as a physician that 

4 would typically furnish such item, 

5 service, or group of services; and 

6 ‘‘(IV) is knowledgeable about the 

7 furnishing of, and has experience fur8 nishing, such item, service, or group 

9 of services. 

10 ‘‘(B) APPEAL OF EXEMPTION.—The Sec11 retary shall, through notice and comment rule12 making, establish a process under which a phy13 sician may appeal a revocation under subpara14 graph (A). Such process shall ensure that any 

15 such appeal is resolved within 30 days of such 

16 appeal being submitted under such process. 

17 ‘‘(C) TREATMENT OF UNRESOLVED

18 CLAIMS.—The provisions of paragraph 

19 (1)(A)(ii) shall apply with respect to the treat20 ment of claims for a determination made under 

21 subparagraph (A) in the same manner as such 

22 provisions apply with respect to the treatment 

23 of claims for a determination made under para24 graph (1)(A).’’. 


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1 (b) RULEMAKING.—The Secretary of Health and 

2 Human Services shall, through rulemaking, specify re3 quirements with respect to the use of prior authorization 

4 by Medicare Advantage plans for items and services de5 scribed in subsection (o)(1) of section 1852 of the Social 

6 Security Act (42 U.S.C. 1395w–22), as added by sub7 section (a), to ensure continuity of care for individuals 

8 transitioning to, or between, coverage under such plans 

9 in order to minimize any disruption to ongoing treatment 

10 attributable to prior authorization requirements under 

11 such plans. 

12 (c) REPORT.—Not later than 2 years after the date 

13 of the enactment of this Act, the Secretary of Health and 

14 Human Services shall submit to Congress a report on the 

15 potential impacts of the amendment made by this section 

16 on communities at high risk for health disparities. 

17 SEC. 3. OPPORTUNITY FOR PROVIDERS TO PRESENT CASES 

18 FOR COVERAGE AND PAYMENT DURING THE 

19 PRIOR AUTHORIZATION PROCESS UNDER MA 

20 PLANS. 

21 Section 1852 of the Social Security Act (42 U.S.C. 

22 1395w–22), as amended by section 2, is further amended 

23 by adding at the end the following new subsection: 


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1 ‘‘(p) OPPORTUNITY FOR PROVIDERS TO PRESENT

2 CASES FOR COVERAGE AND PAYMENT DURING THE

3 PRIOR AUTHORIZATION PROCESS.— 

4 ‘‘(1) IN GENERAL.—For plan years beginning 

5 with the second plan year beginning after the date 

6 of the enactment of this subsection, any prior au7 thorization process (as defined in subsection 

8 (o)(1)(B)) with respect to the coverage and payment 

9 for items and services (other than a covered part D 

10 drug) under an MA plan offered by an MA organiza11 tion shall provide, prior to any coverage or payment 

12 determination with respect to an item or service sub13 ject to such process, for an opportunity for a pro14 vider of services or supplier seeking prior authoriza15 tion to furnish such item or service to discuss with 

16 a qualifying physician (as defined in paragraph 

17 (2))— 

18 ‘‘(A) the treatment plan for the individual 

19 who would be furnished such item or service; 

20 and 

21 ‘‘(B) the clinical basis on which the organi22 zation will determine coverage or payment for 

23 such item or service. 

24 ‘‘(2) QUALIFYING PHYSICIAN DEFINED.—For 

25 purposes of paragraph (1), the term ‘qualifying phyVerDate Sep 11 2014 03:36 Aug 15, 2023 Jkt 039200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H4968.IH H4968

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1 sician’ means, with respect to an item or service sub2 ject to a process described in such paragraph that 

3 a provider of services or supplier is seeking to fur4 nish to an individual, a physician that— 

5 ‘‘(A) possesses a current and nonrestricted 

6 license to practice medicine in the State in 

7 which such item or service is to be furnished; 

8 ‘‘(B) is actively engaged in the practice of 

9 medicine in the same or similar specialty as a 

10 provider of services or supplier that would typi11 cally furnish such item or service; and 

12 ‘‘(C) is knowledgeable about the furnishing 

13 of, and has experience furnishing, such item or 

14 service.’’. 

Æ 


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