IB 
Union Calendar No. 512 
117TH CONGRESS 
2D SESSION 
H. R. 8487 
[Report No. 117–696, Part I] 
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 
DECEMBER 30, 2022 
Reported from the Committee on Ways and Means with an amendment 
[Strike out all after the enacting clause and insert the part printed in italic] 
DECEMBER 30, 2022 
Committee on Energy and Commerce discharged; committed to the Committee 
of the Whole House on the State of the Union and ordered to be printed 
[For text of introduced bill, see copy of bill as introduced on July 26, 2022] 
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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. 
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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’’. 
SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO 
THE USE OF PRIOR AUTHORIZATION UNDER 
MEDICARE ADVANTAGE 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) 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 paragraph 
(2); and 
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‘‘(ii) meet the enrollee protection stand-
ards 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 requirements 
specified in paragraph (3). 
‘‘(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 Medi-
care Advantage plan with respect to an ap-
plicable item or service to be furnished to 
an individual and a response, in accord-
ance 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. 
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‘‘(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 
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 final-
ize any requirements described in clause 
(ii)(II) . 
‘‘(C) REAL-TIME DECISIONS.— 
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‘‘(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 Ad-
vantage plan with respect to prior author-
ization requests for applicable items and 
services identified by the Secretary pursu-
ant to clause (ii) if such requests are sub-
mitted with all medical or other documenta-
tion 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. 
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‘‘(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 utilize by the Secretary) and any 
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-
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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 
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 pro-
vider 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 func-
tion, no later than 24 hours after receipt 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 cur-
rent medical practice, technology, health 
care industry standards, and other relevant 
information relating to how quickly a Medi-
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care Advantage plan may provide responses 
with respect to prior authorization requests. 
‘‘(vi) 
IMPLEMENTATION.—The 
Sec-
retary shall use notice and comment rule-
making for each of the following: 
‘‘(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 
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prior authorization requirement under 
the plan during the previous plan 
year. 
‘‘(II) The percentage and number 
of specified requests (as defined in sub-
paragraph (F)) approved during the 
previous plan year by the plan in an 
initial determination and the percent-
age and number of specified requests 
denied during such plan year by such 
plan in an initial determination (both 
in the aggregate and categorized by 
each item and service). 
‘‘(III) The percentage and number 
of specified requests submitted during 
the previous plan year that were made 
with respect to an item or service iden-
tified 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 number 
of specified requests submitted during 
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the previous plan year that were made 
with respect to an item or service iden-
tified by the Secretary pursuant to 
paragraph (2)(C)(ii) for such plan 
year that were approved (categorized 
by each item and service). 
‘‘(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, broken 
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-
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proved, by the plan during the pre-
vious plan year through the utilization 
of decision support technology, artifi-
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 service, 
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 number 
of specified requests that were excluded 
from the calculation described in sub-
clause (VIII) based on the plan’s deter-
mination that such requests were not 
submitted with the medical or other 
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documentation required to be sub-
mitted by the plan. 
‘‘(X) Information on each occur-
rence during the previous plan year in 
which, during a surgical or medical 
procedure involving the furnishing of 
an applicable item or service with re-
spect to which such plan had approved 
a prior authorization request, the pro-
vider of services or supplier furnishing 
such item or service determined that a 
different or additional item or service 
was medically necessary, including a 
specification of whether such plan sub-
sequently approved the furnishing of 
such different 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)) received 
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by such plan during the previous plan 
year that were related to a prior au-
thorization requirement. 
‘‘(XIII) Such other information as 
the Secretary determines appropriate. 
‘‘(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 poli-
cies or procedures used by the plan for 
making determinations with respect to 
prior authorization requests; 
‘‘(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 determinations 
and an itemization of the medical or 
other documentation required to be 
submitted by a provider or supplier 
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 determinations 
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with respect to prior authorization re-
quests 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 num-
ber of specified requests made with respect to an 
individual and an item or service that were de-
nied by the plan during the preceding plan year 
in an initial determination based on such re-
quests failing to demonstrate that such individ-
uals 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 sub-
paragraph (A)(ii)(II) to providers of serv-
ices and suppliers in accordance with such 
subparagraph; and 
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‘‘(ii) access to such criteria to enrollees 
in 
accordance 
with 
subparagraph 
(A)(ii)(III). 
‘‘(D) PUBLICATION OF INFORMATION.—The 
Secretary shall publish all information described 
in subparagraph (A)(i) and subparagraph (B) 
on a public website of the Centers for Medicare 
& Medicaid Services. Such information 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 recommendations, as 
appropriate, on any improvement that should be 
made to the electronic prior authorization pro-
grams 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 authoriza-
tion 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 waiv-
er or modification of prior authorization require-
ments based on the performance of such pro-
viders and suppliers in demonstrating compli-
ance with such requirements, such as adherence 
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 Advantage 
plan, any item or service for which benefits are avail-
able 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 submit 
to Congress a report containing an evaluation of 
the implementation of the requirements of this 
subsection and an analysis of issues in imple-
menting such requirements faced by Medicare 
Advantage plans. 
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‘‘(B) HHS.—Not later than the end of the 
fifth plan year beginning after the date of the en-
actment of this subsection, and biennially there-
after 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 report, 
the fourth plan year beginning after the 
date of the enactment of this subsection; and 
‘‘(ii) in the case of a subsequent report, 
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 submitted 
on or after the first day of the third plan year begin-
ning after the date of the enactment of the Improving 
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Seniors’ Timely Access to Care Act of 2022, not later 
than 24 hours)’’ after ‘‘72 hours’’. 
(3) by adding at the end the following new para-
graph: 
‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU-
THORIZATION REQUESTS.—Subject to paragraph (3) 
and subsection (o), in the case of an organization de-
termination made with respect to a prior authoriza-
tion 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 en-
actment of this paragraph, such determination shall 
be made no later than 7 days (or such shorter time-
frame as the Secretary may specify through notice 
and comment rulemaking, taking into account en-
rollee 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 es-
tablished under section 1841 of such Act (42 U.S.C. 1395t) 
(in such proportion as determined appropriate by the Sec-
retary) to the Centers for Medicare & Medicaid Services 
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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. 
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