117TH CONGRESS 

2D SESSION H. R. 3173 

AN ACT 

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, 
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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 2022’’. 

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 the third plan year be17 ginning after the date of the enactment of this 

18 subsection— 

19 ‘‘(i) establish the electronic prior au20 thorization program described in para21 graph (2); and 

22 ‘‘(ii) meet the enrollee protection 

23 standards specified pursuant to paragraph 

24 (4); and 

25 ‘‘(B) beginning with the fourth plan year 

26 beginning after the date of the enactment of 
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1 this subsection, meet the transparency require2 ments specified in paragraph (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 attachment relating to such 

18 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— 

6 ‘‘(I) applicable technical stand7 ards adopted by the Secretary pursu8 ant to section 1173; and 

9 ‘‘(II) other requirements to pro10 mote the standardization and stream11 lining of electronic transactions under 

12 this part specified by the Secretary. 

13 ‘‘(iii) DEADLINE FOR SPECIFICATION

14 OF ADDITIONAL REQUIREMENTS.—Not 

15 later than July 1, 2023, the Secretary 

16 shall finalize requirements described in 

17 clause (ii)(II). 

18 ‘‘(C) REAL-TIME DECISIONS.— 

19 ‘‘(i) IN GENERAL.—Subject to clause 

20 (iv), the program described in subpara21 graph (A) shall provide for real-time deci22 sions (as defined by the Secretary in ac23 cordance with clause (v)) by a Medicare 

24 Advantage plan with respect to prior au25 thorization requests for applicable items 
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1 and services identified by the Secretary 

2 pursuant to clause (ii) if such requests are 

3 submitted with all medical or other docu4 mentation required by such plan. 

5 ‘‘(ii) IDENTIFICATION OF ITEMS AND

6 SERVICES.— 

7 ‘‘(I) IN GENERAL.—For purposes 

8 of clause (i), the Secretary shall iden9 tify, not later than the date on which 

10 the initial announcement described in 

11 section 1853(b)(1)(B)(i) for the third 

12 plan year beginning after the date of 

13 the enactment of this subsection is re14 quired to be announced, applicable 

15 items and services for which prior au16 thorization requests are routinely ap17 proved. 

18 ‘‘(II) UPDATES.—The Secretary 

19 shall consider updating the applicable 

20 items and services identified under 

21 subclause (I) based on the information 

22 described in paragraph (3)(A)(i) (if 

23 available and determined practicable 

24 to utilize by the Secretary) and any 

25 other information determined appro-
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1 priate by the Secretary not less fre2 quently than biennially. The Secretary 

3 shall announce any such update that 

4 is to apply with respect to a plan year 

5 not later than the date on which the 

6 initial announcement described in sec7 tion 1853(b)(1)(B)(i) for such plan 

8 year is required to be announced. 

9 ‘‘(iii) REQUEST FOR INFORMATION.— 

10 The Secretary shall issue a request for in11 formation for purposes of initially identi12 fying applicable items and services under 

13 clause (ii)(I). 

14 ‘‘(iv) EXCEPTION FOR EXTENUATING

15 CIRCUMSTANCES.—In the case of a prior 

16 authorization request submitted to a Medi17 care Advantage plan for an individual en18 rolled in such plan during a plan year with 

19 respect to an item or service identified by 

20 the Secretary pursuant to clause (ii) for 

21 such plan year, such plan may, in lieu of 

22 providing a real-time decision with respect 

23 to such request in accordance with clause 

24 (i), delay such decision under extenuating 

25 circumstances (as specified by the Sec-
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1 retary), provided that such decision is pro2 vided no later than 72 hours after receipt 

3 of such request (or, in the case that the 

4 provider of services or supplier submitting 

5 such request has indicated that such delay 

6 may seriously jeopardize such individual’s 

7 life, health, or ability to regain maximum 

8 function, no later than 24 hours after re9 ceipt of such request). 

10 ‘‘(v) DEFINITION OF REAL-TIME DECI11 SION.—In establishing the definition of a 

12 real-time decision for purposes of clause 

13 (i), the Secretary shall take into account 

14 current medical practice, technology, 

15 health care industry standards, and other 

16 relevant information relating to how quick17 ly a Medicare Advantage plan may provide 

18 responses with respect to prior authoriza19 tion requests. 

20 ‘‘(vi) IMPLEMENTATION.—The Sec21 retary shall use notice and comment rule22 making for each of the following: 

23 ‘‘(I) Establishing the definition 

24 of a ‘real-time decision’ for purposes 

25 of clause (i). 
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1 ‘‘(II) Updating such definition. 

2 ‘‘(III) Initially identifying appli3 cable items or services pursuant to 

4 clause (ii)(I). 

5 ‘‘(IV) Updating applicable items 

6 and services so identified as described 

7 in clause (ii)(II). 

8 ‘‘(3) TRANSPARENCY REQUIREMENTS.— 

9 ‘‘(A) IN GENERAL.—For purposes of para10 graph (1)(B), the transparency requirements 

11 specified in this paragraph are, with respect to 

12 a Medicare Advantage plan, the following: 

13 ‘‘(i) The plan, annually and in a man14 ner specified by the Secretary, shall submit 

15 to the Secretary the following information: 

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

17 and services that were subject to a 

18 prior authorization requirement under 

19 the plan during the previous plan 

20 year. 

21 ‘‘(II) The percentage and number 

22 of specified requests (as defined in 

23 subparagraph (F)) approved during 

24 the previous plan year by the plan in 

25 an initial determination and the per-
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1 centage and number of specified re2 quests denied during such plan year 

3 by such plan in an initial determina4 tion (both in the aggregate and cat5 egorized by each item and service). 

6 ‘‘(III) The percentage and num7 ber of specified requests submitted 

8 during the previous plan year that 

9 were made with respect to an item or 

10 service identified by the Secretary 

11 pursuant to paragraph (2)(C)(ii) for 

12 such plan year, and the percentage 

13 and number of such requests that 

14 were subject to an exception under 

15 paragraph (2)(C)(iv) (categorized by 

16 each item and service). 

17 ‘‘(IV) The percentage and num18 ber of specified requests submitted 

19 during the previous plan year that 

20 were made with respect to an item or 

21 service identified by the Secretary 

22 pursuant to paragraph (2)(C)(ii) for 

23 such plan year that were approved 

24 (categorized by each item and serv25 ice). 
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1 ‘‘(V) The percentage and number 

2 of specified requests that were denied 

3 during the previous plan year by the 

4 plan in an initial determination and 

5 that were subsequently appealed. 

6 ‘‘(VI) The number of appeals of 

7 specified requests resolved during the 

8 preceding plan year, and the percent9 age and number of such resolved ap10 peals that resulted in approval of the 

11 furnishing of the item or service that 

12 was the subject of such request, cat13 egorized by each applicable item and 

14 service and categorized by each level 

15 of appeal (including judicial review). 

16 ‘‘(VII) The percentage and num17 ber of specified requests that were de18 nied, and the percentage and number 

19 of specified requests that were ap20 proved, by the plan during the pre21 vious plan year through the utilization 

22 of decision support technology, artifi23 cial intelligence technology, machine24 learning technology, clinical decision- 
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1 making technology, or any other tech2 nology specified by the Secretary. 

3 ‘‘(VIII) The average and the me4 dian amount of time (in hours) that 

5 elapsed during the previous plan year 

6 between the submission of a specified 

7 request to the plan and a determina8 tion by the plan with respect to such 

9 request for each such item and serv10 ice, excluding any such requests that 

11 were not submitted with the medical 

12 or other documentation required to be 

13 submitted by the plan. 

14 ‘‘(IX) The percentage and num15 ber of specified requests that were ex16 cluded from the calculation described 

17 in subclause (VIII) based on the 

18 plan’s determination that such re19 quests were not submitted with the 

20 medical or other documentation re21 quired to be submitted by the plan. 

22 ‘‘(X) Information on each occur23 rence during the previous plan year in 

24 which, during a surgical or medical 

25 procedure involving the furnishing of 
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1 an applicable item or service with re2 spect to which such plan had ap3 proved a prior authorization request, 

4 the provider of services or supplier 

5 furnishing such item or service deter6 mined that a different or additional 

7 item or service was medically nec8 essary, including a specification of 

9 whether such plan subsequently ap10 proved the furnishing of such dif11 ferent or additional item or service. 

12 ‘‘(XI) A disclosure and descrip13 tion of any technology described in 

14 subclause (VII) that the plan utilized 

15 during the previous plan year in mak16 ing determinations with respect to 

17 specified requests. 

18 ‘‘(XII) The number of grievances 

19 (as described in subsection (f)) re20 ceived by such plan during the pre21 vious plan year that were related to a 

22 prior authorization requirement. 

23 ‘‘(XIII) Such other information 

24 as the Secretary determines appro25 priate. 
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1 ‘‘(ii) The plan shall provide— 

2 ‘‘(I) to each provider or supplier 

3 who seeks to enter into a contract 

4 with such plan to furnish applicable 

5 items and services under such plan, 

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

7 any policies or procedures used by the 

8 plan for making determinations with 

9 respect to prior authorization re10 quests; 

11 ‘‘(II) to each such provider and 

12 supplier that enters into such a con13 tract, access to the criteria used by 

14 the plan for making such determina15 tions and an itemization of the med16 ical or other documentation required 

17 to be submitted by a provider or sup18 plier with respect to such a request; 

19 and 

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

21 upon request, access to the criteria 

22 used by the plan for making deter23 minations with respect to prior au24 thorization requests for an item or 

25 service. 
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1 ‘‘(B) OPTION FOR PLAN TO PROVIDE CER2 TAIN ADDITIONAL INFORMATION.—As part of 

3 the information described in subparagraph 

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

5 year, a Medicare Advantage plan may elect to 

6 include information regarding the percentage 

7 and number of specified requests made with re8 spect to an individual and an item or service 

9 that were denied by the plan during the pre10 ceding plan year in an initial determination 

11 based on such requests failing to demonstrate 

12 that such individuals met the clinical criteria 

13 established by such plan to receive such items 

14 or services. 

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

16 through notice and comment rulemaking, estab17 lish requirements for Medicare Advantage plans 

18 regarding the provision of— 

19 ‘‘(i) access to criteria described in 

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

21 services and suppliers in accordance with 

22 such subparagraph; and 

23 ‘‘(ii) access to such criteria to enroll24 ees in accordance with subparagraph 

25 (A)(ii)(III). 
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1 ‘‘(D) PUBLICATION OF INFORMATION.— 

2 The Secretary shall publish information de3 scribed in subparagraph (A)(i) and subpara4 graph (B) on a public website of the Centers 

5 for Medicare & Medicaid Services. Such infor6 mation shall be so published on an individual 

7 plan level and may in addition be aggregated in 

8 such manner as determined appropriate by the 

9 Secretary. 

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

11 years after the date information is first sub12 mitted under subparagraph (A)(i), the Medicare 

13 Payment Advisory Commission shall submit to 

14 Congress a report on such information that in15 cludes a descriptive analysis of the use of prior 

16 authorization. As appropriate, the Commission 

17 should report on statistics including the fre18 quency of appeals and overturned decisions. 

19 The Commission shall provide recommenda20 tions, as appropriate, on any improvement that 

21 should be made to the electronic prior author22 ization programs of Medicare Advantage plans. 

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

24 purposes of this paragraph, the term ‘specified 

25 request’ means a prior authorization request 
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1 made with respect to an applicable item or serv2 ice. 

3 ‘‘(4) ENROLLEE PROTECTION STANDARDS.— 

4 For purposes of paragraph (1)(A)(ii), the Secretary 

5 shall, through notice and comment rulemaking, 

6 specify the following enrollee protection standards 

7 with respect to the use of prior authorization by 

8 Medicare Advantage plans for applicable items and 

9 services: 

10 ‘‘(A) Adoption of transparent prior author11 ization programs developed in consultation with 

12 enrollees and with providers and suppliers with 

13 contracts in effect with such plans for fur14 nishing such items and services under such 

15 plans; 

16 ‘‘(B) Allowing for the waiver or modifica17 tion of prior authorization requirements based 

18 on the performance of such providers and sup19 pliers in demonstrating compliance with such 

20 requirements, such as adherence to evidence21 based medical guidelines and other quality cri22 teria; and 

23 ‘‘(C) Conducting annual reviews of such 

24 items and services for which prior authorization 

25 requirements are imposed under such plans 
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1 through a process that takes into account input 

2 from enrollees and from providers and suppliers 

3 with such contracts in effect and is based on 

4 consideration of prior authorization data from 

5 previous plan years and analyses of current cov6 erage criteria. 

7 ‘‘(5) APPLICABLE ITEM OR SERVICE.—For pur8 poses of this subsection, the term ‘applicable item or 

9 service’ means, with respect to a Medicare Advan10 tage plan, any item or service for which benefits are 

11 available under such plan, other than a covered part 

12 D drug. 

13 ‘‘(6) REPORTS TO CONGRESS.— 

14 ‘‘(A) GAO.—Not later than the end of the 

15 fourth plan year beginning on or after the date 

16 of the enactment of this subsection, the Comp17 troller General of the United States shall sub18 mit to Congress a report containing an evalua19 tion of the implementation of the requirements 

20 of this subsection and an analysis of issues in 

21 implementing such requirements faced by Medi22 care Advantage plans. 

23 ‘‘(B) HHS.—Not later than the end of the 

24 fifth plan year beginning after the date of the 

25 enactment of this subsection, and biennially 
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1 thereafter through the date that is 10 years 

2 after such date of enactment, the Secretary 

3 shall submit to Congress a report containing a 

4 description of the information submitted under 

5 paragraph (3)(A)(i) during— 

6 ‘‘(i) in the case of the first such re7 port, the fourth plan year beginning after 

8 the date of the enactment of this sub9 section; and 

10 ‘‘(ii) in the case of a subsequent re11 port, the 2 plan years preceding the year 

12 of the submission of such report.’’. 

13 (b) ENSURING TIMELY RESPONSES FOR ALL PRIOR

14 AUTHORIZATION REQUESTS SUBMITTED UNDER PART

15 C.—Section 1852(g) of the Social Security Act (42 U.S.C. 

16 1395w–22(g)) is amended— 

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

18 accordance with paragraph (6)’’ after ‘‘paragraph 

19 (3)’’; 

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

21 subject to subsection (o), with respect to prior au22 thorization requests submitted on or after the first 

23 day of the third plan year beginning after the date 

24 of the enactment of the Improving Seniors’ Timely 
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1 Access to Care Act of 2022, not later than 24 

2 hours)’’ after ‘‘72 hours’’. 

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

4 paragraph: 

5 ‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU6 THORIZATION REQUESTS.—Subject to paragraph (3) 

7 and subsection (o), in the case of an organization 

8 determination made with respect to a prior author9 ization request for an item or service to be furnished 

10 to an individual submitted on or after the first day 

11 of the third plan year beginning after the date of the 

12 enactment of this paragraph, the organization shall 

13 notify the enrollee (and the physician involved, as 

14 appropriate) of such determination no later than 7 

15 days (or such shorter timeframe as the Secretary 

16 may specify through notice and comment rule17 making, taking into account enrollee and stakeholder 

18 feedback) after receipt of such request.’’. 

19 SEC. 3. FUNDING. 

20 The Secretary of Health and Human Services shall 

21 provide for the transfer, from the Federal Hospital Insur22 ance Trust Fund established under section 1817 of the 

23 Social Security Act (42 U.S.C. 1395i) and the Federal 

24 Supplementary Medical Insurance Trust Fund established 

25 under section 1841 of such Act (42 U.S.C. 1395t) (in such 
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1 proportion as determined appropriate by the Secretary) to 

2 the Centers for Medicare & Medicaid Services Program 

3 Management Account, of $25,000,000 for fiscal year 

4 2022, to remain available until expended, for purposes of 

5 carrying out the amendments made by this Act. 

Passed the House of Representatives September 14, 

2022. 

Attest: 

Clerk. 

117TH CONGRESS 

2D SESSION H. R. 3173 

AN ACT 

To amend title XVIII of the Social Security Act to 

plans, and for other purposes. prior authorization under Medicare Advantage establish requirements with respect to the use of