I 
117TH CONGRESS 
2D SESSION 
H. R. 8487 
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 
JULY 26, 2022 
Ms. DELBENE (for herself, Mr. KELLY of Pennsylvania, Mr. BERA, and Mr. 
BUCSHON) introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction 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 authoriza-
tion under Medicare Advantage plans, and for other pur-
poses. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Improving Seniors’ 
Timely Access to Care Act of 2022’’. 
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SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO 
THE USE OF PRIOR AUTHORIZATION UNDER 
MEDICARE ADVANTAGE PLANS. 
(a) IN GENERAL.—Section 1852 of the Social Secu-
rity Act (42 U.S.C. 1395w–22) is amended by adding at 
the end the following new subsection: 
‘‘(o) PRIOR AUTHORIZATION REQUIREMENTS.— 
‘‘(1) IN GENERAL.—In the case of a Medicare 
Advantage plan that imposes any prior authorization 
requirement with respect to any applicable item or 
service (as defined in paragraph (5)) during a plan 
year, such plan shall— 
‘‘(A) beginning with the third plan year be-
ginning after the date of the enactment of this 
subsection— 
‘‘(i) establish the electronic prior au-
thorization program described in para-
graph (2); and 
‘‘(ii) meet the enrollee protection 
standards specified pursuant to paragraph 
(4); and 
‘‘(B) beginning with the fourth plan year 
beginning after the date of the enactment of 
this subsection, meet the transparency require-
ments specified in paragraph (3). 
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‘‘(2) ELECTRONIC PRIOR AUTHORIZATION PRO-
GRAM.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1)(A), the electronic prior authorization 
program described in this paragraph is a pro-
gram that provides for the secure electronic 
transmission of— 
‘‘(i) a prior authorization request 
from a provider of services or supplier to 
a Medicare Advantage plan with respect to 
an applicable item or service to be fur-
nished to an individual and a response, in 
accordance with this paragraph, from such 
plan to such provider or supplier; and 
‘‘(ii) any health claims attachment (as 
defined 
for 
purposes 
of 
section 
1173(a)(2)(B)) relating to such request or 
response. 
‘‘(B) ELECTRONIC TRANSMISSION.— 
‘‘(i) EXCLUSIONS.—For purposes of 
this paragraph, a facsimile, a proprietary 
payer portal that does not meet standards 
specified by the Secretary, or an electronic 
form shall not be treated as an electronic 
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transmission described in subparagraph 
(A). 
‘‘(ii) 
STANDARDS.—An 
electronic 
transmission described in subparagraph 
(A) shall comply with— 
‘‘(I) applicable technical stand-
ards adopted by the Secretary pursu-
ant to section 1173; and 
‘‘(II) any other requirements to 
promote 
the 
standardization 
and 
streamlining of electronic transactions 
under this part specified by the Sec-
retary. 
‘‘(iii) DEADLINE FOR SPECIFICATION 
OF
ADDITIONAL
REQUIREMENTS.—Not 
later than July 1, 2023, the Secretary 
shall finalize any requirements described in 
clause (ii)(II). 
‘‘(C) REAL-TIME DECISIONS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(iv), the program described in subpara-
graph (A) shall provide for real-time deci-
sions (as defined by the Secretary in ac-
cordance with clause (v)) by a Medicare 
Advantage plan with respect to prior au-
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thorization requests for applicable items 
and services identified by the Secretary 
pursuant to clause (ii) if such requests are 
submitted with all medical or other docu-
mentation required by such plan. 
‘‘(ii) IDENTIFICATION OF ITEMS AND 
SERVICES.— 
‘‘(I) IN GENERAL.—For purposes 
of clause (i), the Secretary shall iden-
tify, not later than the date on which 
the initial announcement described in 
section 1853(b)(1)(B)(i) for the third 
plan year beginning after the date of 
the enactment of this subsection is re-
quired to be announced, applicable 
items and services for which prior au-
thorization requests are routinely ap-
proved. 
‘‘(II) UPDATES.—The Secretary 
shall consider updating the applicable 
items and services identified under 
subclause (I) based on the information 
described in paragraph (3)(A)(i) (if 
available and determined practicable 
to use by the Secretary) and any 
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other information determined appro-
priate by the Secretary not less fre-
quently than biennially. The Secretary 
shall announce any such update that 
is to apply with respect to a plan year 
not later than the date on which the 
initial announcement described in sec-
tion 1853(b)(1)(B)(i) for such plan 
year is required to be announced. 
‘‘(iii) REQUEST FOR INFORMATION.— 
The Secretary shall issue a request for in-
formation for purposes of initially identi-
fying applicable items and services under 
clause (ii)(I). 
‘‘(iv) EXCEPTION FOR EXTENUATING 
CIRCUMSTANCES.—In the case of a prior 
authorization request submitted to a Medi-
care Advantage plan for an individual en-
rolled in such plan during a plan year with 
respect to an item or service identified by 
the Secretary pursuant to clause (ii) for 
such plan year, such plan may, in lieu of 
providing a real-time decision with respect 
to such request in accordance with clause 
(i), delay such decision under extenuating 
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circumstances (as specified by the Sec-
retary), provided that such decision is pro-
vided no later than 72 hours after receipt 
of such request (or, in the case that the 
provider of services or supplier submitting 
such request has indicated that such delay 
may seriously jeopardize such individual’s 
life, health, or ability to regain maximum 
function, no later than 24 hours after re-
ceipt of such request). 
‘‘(v) DEFINITION OF REAL-TIME DECI-
SION.—In establishing the definition of a 
real-time decision for purposes of clause 
(i), the Secretary shall take into account 
current 
medical 
practice, 
technology, 
health care industry standards, and other 
relevant information relating to how quick-
ly a Medicare Advantage plan may provide 
responses with respect to prior authoriza-
tion requests. 
‘‘(vi) IMPLEMENTATION.—The Sec-
retary shall use notice and comment rule-
making for each of the following: 
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‘‘(I) Establishing the definition 
of a ‘real-time decision’ for purposes 
of clause (i). 
‘‘(II) Updating such definition. 
‘‘(III) Initially identifying appli-
cable items or services pursuant to 
clause (ii)(I). 
‘‘(IV) Updating applicable items 
and services so identified as described 
in clause (ii)(II). 
‘‘(3) TRANSPARENCY REQUIREMENTS.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1)(B), the transparency requirements 
specified in this paragraph are, with respect to 
a Medicare Advantage plan, the following: 
‘‘(i) The plan, annually and in a man-
ner specified by the Secretary, shall submit 
to the Secretary the following information: 
‘‘(I) A list of all applicable items 
and services that were subject to a 
prior authorization requirement under 
the plan during the previous plan 
year. 
‘‘(II) The percentage and number 
of specified requests (as defined in 
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subparagraph (F)) approved during 
the previous plan year by the plan in 
an initial determination and the per-
centage and number of specified re-
quests denied during such plan year 
by such plan in an initial determina-
tion (both in the aggregate and cat-
egorized by each item and service). 
‘‘(III) The percentage and num-
ber of specified requests submitted 
during the previous plan year that 
were made with respect to an item or 
service identified by the Secretary 
pursuant to paragraph (2)(C)(ii) for 
such plan year, and the percentage 
and number of such requests that 
were subject to an exception under 
paragraph (2)(C)(iv) (categorized by 
each item and service). 
‘‘(IV) The percentage and num-
ber of specified requests submitted 
during the previous plan year that 
were made with respect to an item or 
service identified by the Secretary 
pursuant to paragraph (2)(C)(ii) for 
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such plan year that were approved 
(categorized by each item and serv-
ice). 
‘‘(V) The percentage and number 
of specified requests that were denied 
during the previous plan year by the 
plan in an initial determination and 
that were subsequently appealed. 
‘‘(VI) The number of appeals of 
specified requests resolved during the 
preceding plan year, and the percent-
age and number of such resolved ap-
peals that resulted in approval of the 
furnishing of the item or service that 
was the subject of such request, bro-
ken down by each applicable item and 
service and broken down by each level 
of appeal (including judicial review). 
‘‘(VII) The percentage and num-
ber of specified requests that were de-
nied, and the percentage and number 
of specified requests that were ap-
proved, by the plan during the pre-
vious plan year through the utilization 
of decision support technology, artifi-
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cial intelligence technology, machine- 
learning technology, clinical decision- 
making technology, or any other tech-
nology specified by the Secretary. 
‘‘(VIII) The average and the me-
dian amount of time (in hours) that 
elapsed during the previous plan year 
between the submission of a specified 
request to the plan and a determina-
tion by the plan with respect to such 
request for each such item and serv-
ice, excluding any such requests that 
were not submitted with the medical 
or other documentation required to be 
submitted by the plan. 
‘‘(IX) The percentage and num-
ber of specified requests that were ex-
cluded from the calculation described 
in subclause (VIII) based on the 
plan’s determination that such re-
quests were not submitted with the 
medical or other documentation re-
quired to be submitted by the plan. 
‘‘(X) Information on each occur-
rence during the previous plan year in 
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which, during a surgical or medical 
procedure involving the furnishing of 
an applicable item or service with re-
spect to which such plan had ap-
proved a prior authorization request, 
the provider of services or supplier 
furnishing such item or service deter-
mined that a different or additional 
item or service was medically nec-
essary, including a specification of 
whether such plan subsequently ap-
proved the furnishing of such dif-
ferent or additional item or service. 
‘‘(XI) A disclosure and descrip-
tion of any technology described in 
subclause (VII) that the plan utilized 
during the previous plan year in mak-
ing determinations with respect to 
specified requests. 
‘‘(XII) The number of grievances 
(as described in subsection (f)) re-
ceived by such plan during the pre-
vious plan year that were related to a 
prior authorization requirement. 
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‘‘(XIII) Such other information 
as the Secretary determines appro-
priate. 
‘‘(ii) The plan shall provide— 
‘‘(I) to each provider or supplier 
who seeks to enter into a contract 
with such plan to furnish applicable 
items and services under such plan, 
the list described in clause (i)(I) and 
any policies or procedures used by the 
plan for making determinations with 
respect to prior authorization re-
quests; 
‘‘(II) to each such provider and 
supplier that enters into such a con-
tract, access to the criteria used by 
the plan for making such determina-
tions and an itemization of the med-
ical or other documentation required 
to be submitted by a provider or sup-
plier with respect to such a request; 
and 
‘‘(III) to an enrollee of the plan 
upon request, access to the criteria 
used by the plan for making deter-
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minations with respect to prior au-
thorization requests for an item or 
service. 
‘‘(B) OPTION FOR PLAN TO PROVIDE CER-
TAIN ADDITIONAL INFORMATION.—As part of 
the information described in subparagraph 
(A)(i) provided to the Secretary during a plan 
year, a Medicare Advantage plan may elect to 
include information regarding the percentage 
and number of specified requests made with re-
spect to an individual and an item or service 
that were denied by the plan during the pre-
ceding plan year in an initial determination 
based on such requests failing to demonstrate 
that such individuals met the clinical criteria 
established by such plan to receive such items 
or services. 
‘‘(C) REGULATIONS.—The Secretary shall, 
through notice and comment rulemaking, estab-
lish requirements for Medicare Advantage plans 
regarding the provision of— 
‘‘(i) access to criteria described in 
subparagraph (A)(ii)(II) to providers of 
services and suppliers in accordance with 
such subparagraph; and 
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‘‘(ii) access to such criteria to enroll-
ees in accordance with subparagraph 
(A)(ii)(III). 
‘‘(D) PUBLICATION
OF
INFORMATION.— 
The Secretary shall publish all information de-
scribed in subparagraph (A)(i) and subpara-
graph (B) on a public website of the Centers 
for Medicare & Medicaid Services. Such infor-
mation shall be so published on an individual 
plan level and may in addition be aggregated in 
such manner as determined appropriate by the 
Secretary. 
‘‘(E) MEDPAC REPORT.—Not later than 3 
years after the date information is first sub-
mitted under subparagraph (A)(i), the Medicare 
Payment Advisory Commission shall submit to 
Congress a report on such information that in-
cludes a descriptive analysis of the use of prior 
authorization. As appropriate, the Commission 
should report on statistics including the fre-
quency of appeals and overturned decisions. 
The Commission shall provide recommenda-
tions, as appropriate, on any improvement that 
should be made to the electronic prior author-
ization programs of Medicare Advantage plans. 
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‘‘(F) SPECIFIED REQUEST DEFINED.—For 
purposes of this paragraph, the term ‘specified 
request’ means a prior authorization request 
made with respect to an applicable item or serv-
ice. 
‘‘(4) ENROLLEE
PROTECTION
STANDARDS.— 
The Secretary of Health and Human Services shall, 
through notice and comment rulemaking, specify re-
quirements with respect to the use of prior author-
ization by Medicare Advantage plans for applicable 
items and services to ensure— 
‘‘(A) that such plans adopt transparent 
prior authorization programs developed in con-
sultation with enrollees and with providers and 
suppliers with contracts in effect with such 
plans for furnishing such items and services 
under such plans; 
‘‘(B) that such programs allow for the 
waiver or modification of prior authorization re-
quirements based on the performance of such 
providers and suppliers in demonstrating com-
pliance with such requirements, such as adher-
ence to evidence-based medical guidelines and 
other quality criteria; and 
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‘‘(C) that such plans conduct annual re-
views of such items and services for which prior 
authorization requirements are imposed under 
such plans through a process that takes into ac-
count input from enrollees and from providers 
and suppliers with such contracts in effect and 
is based on consideration of prior authorization 
data from previous plan years and analyses of 
current coverage criteria. 
‘‘(5) APPLICABLE ITEM OR SERVICE.—For pur-
poses of this subsection, the term ‘applicable item or 
service’ means, with respect to a Medicare Advan-
tage plan, any item or service for which benefits are 
available under such plan, other than a covered part 
D drug. 
‘‘(6) REPORTS TO CONGRESS.— 
‘‘(A) GAO.—Not later than the end of the 
fourth plan year beginning on or after the date 
of the enactment of this subsection, the Comp-
troller General of the United States shall sub-
mit to Congress a report containing an evalua-
tion of the implementation of the requirements 
of this subsection and an analysis of issues in 
implementing such requirements faced by Medi-
care Advantage plans. 
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‘‘(B) HHS.—Not later than the end of the 
fifth plan year beginning after the date of the 
enactment of this subsection, and biennially 
thereafter through the date that is 10 years 
after such date of enactment, the Secretary 
shall submit to Congress a report containing a 
description of the information submitted under 
paragraph (3)(A)(i) during— 
‘‘(i) in the case of the first such re-
port, the fourth plan year beginning after 
the date of the enactment of this sub-
section; and 
‘‘(ii) in the case of a subsequent re-
port, the 2 plan years preceding the year 
of the submission of such report.’’. 
(b) ENSURING TIMELY RESPONSES FOR ALL PRIOR 
AUTHORIZATION REQUESTS SUBMITTED UNDER PART 
C.—Section 1852(g) of the Social Security Act (42 U.S.C. 
1395w–22(g)) is amended— 
(1) in paragraph (1)(A), by inserting ‘‘and in 
accordance with paragraph (6)’’ after ‘‘paragraph 
(3)’’; 
(2) in paragraph (3)(B)(iii), by inserting ‘‘(or, 
with respect to prior authorization requests sub-
mitted on or after the first day of the third plan 
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year beginning after the date of the enactment of 
the Improving Seniors’ Timely Access to Care Act of 
2022, not later than 24 hours)’’ after ‘‘72 hours’’; 
and 
(3) by adding at the end the following new 
paragraph: 
‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU-
THORIZATION REQUESTS.—Subject to paragraph (3) 
and subsection (o), in the case of an organization 
determination made with respect to a prior author-
ization request for an item or service to be furnished 
to an individual submitted on or after the first day 
of the third plan year beginning after the date of the 
enactment of this paragraph, such determination 
shall be made no later than 7 days (or such shorter 
timeframe as the Secretary may specify through no-
tice and comment rulemaking, taking into account 
enrollee and stakeholder feedback) after receipt of 
such request.’’. 
(c) FUNDING.—The Secretary of Health and Human 
Services shall provide for the transfer, from the Federal 
Hospital Insurance Trust Fund established under section 
1817 of the Social Security Act (42 U.S.C. 1395i) and 
the Federal Supplementary Medical Insurance Trust 
Fund established under section 1841 of such Act (42 
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U.S.C. 1395t) (in such proportion as determined appro-
priate by the Secretary) to the Centers for Medicare & 
Medicaid Services Program Management Account, of 
$15,000,000 for fiscal year 2022, to remain available until 
expended, for purposes of carrying out the amendments 
made by this Act. 
Æ 
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