128 
OFF-CAMPUS OUTPATIENT DEPARTMENT OF A 
PROVIDER.— 
‘‘(i) IN GENERAL.—Subject to clause 
(iii), in the case of specified OPD services 
(as defined in clause (v)) that are fur-
nished during 2025 or a subsequent year 
by an off-campus outpatient department of 
a provider (as defined in clause (iv)) (or, 
in the case of an off-campus outpatient de-
partment of a provider that is a hospital 
described in section 1886(d)(1)(B)(v), or is 
located in a rural area or a health profes-
sional shortage area, such services that are 
furnished during 2026 or a subsequent 
year), there shall be substituted for the 
amount otherwise determined under this 
subsection for such service and year an 
amount equal to the payment amount that 
would have been payable under the applica-
ble payment system under this part (other 
than under this subsection) had such serv-
ices been furnished by such a department 
subject to such payment system pursuant 
to paragraph (21)(C). 
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‘‘(ii) NOT BUDGET NEUTRAL IMPLE-
MENTATION.—In making any budget neu-
trality adjustments under this subsection 
for 2025 or a subsequent year, the Sec-
retary shall not take into account the re-
duced expenditures that result from the 
application of this subparagraph. 
‘‘(iii) 
TRANSITION.—The 
Secretary 
shall provide for a 4-year phase-in of the 
application of clause (i), with clause (i) 
being fully applicable for specified OPD 
services beginning with 2028 (or in the 
case of an off-campus outpatient depart-
ment of a provider that is a hospital de-
scribed in section 1886(d)(1)(B)(v), or is 
located in a rural area or a health profes-
sional shortage area, beginning with 2029). 
‘‘(iv) OFF-CAMPUS DEPARTMENT OF A 
PROVIDER.—For purposes of this subpara-
graph, the term ‘off-campus outpatient de-
partment of a provider’ means a depart-
ment of a provider (as defined in section 
413.65(a)(2) of title 42, Code of Federal 
Regulations) that is not located— 
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‘‘(I) on the campus (as such term 
is defined in such section) of such 
provider; or 
‘‘(II) within the distance (de-
scribed in such definition of campus) 
from a remote location of a hospital 
facility (as defined in such section). 
‘‘(v) OTHER DEFINITIONS.—For pur-
poses of this subparagraph: 
‘‘(I) DESIGNATED
AMBULATORY 
PAYMENT
CLASSIFICATION
GROUP.— 
The term ‘designated ambulatory pay-
ment classification group’ means an 
ambulatory 
payment 
classification 
group for drug administration serv-
ices. 
‘‘(II) 
HEALTH
PROFESSIONAL 
SHORTAGE
AREA.—The term ‘health 
professional shortage area’ has the 
meaning given such term in section 
332(a)(1)(A) of the Public Health 
Service Act. 
‘‘(III) RURAL AREA.—The term 
‘rural area’ has the meaning given 
such term in section 1886(d)(2)(D). 
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131 
‘‘(IV) 
SPECIFIED
OPD
SERV-
ICES.—The term ‘specified OPD serv-
ices’ means covered OPD services as-
signed to a designated ambulatory 
payment classification group.’’. 
(b) IMPLEMENTATION.—Section 1833(t)(12) of the 
Social Security Act (42 U.S.C. 1395l(t)(12)) is amend-
ed— 
(1) in subparagraph (D), by striking ‘‘and’’ at 
the end; 
(2) in subparagraph (E), by striking the period 
at the end and inserting ‘‘; and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(F) the determination of any payment 
amount under paragraph (16)(H), including the 
transition under clause (iii) of such para-
graph.’’. 
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132 
TITLE III—PATIENT-FOCUSED 
INVESTMENTS 
SEC. 301. 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 
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this subsection, meet the transparency require-
ments 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 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 attachment 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) other requirements to pro-
mote the standardization and stream-
lining of electronic transactions under 
this part specified by the Secretary. 
‘‘(iii) DEADLINE FOR SPECIFICATION 
OF
ADDITIONAL
REQUIREMENTS.—Not 
later than July 1, 2024, the Secretary 
shall finalize 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-
thorization requests for applicable items 
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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 utilize by the Secretary) and any 
other information determined appro-
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136 
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 
circumstances (as specified by the Sec-
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137 
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: 
‘‘(I) Establishing the definition 
of a ‘real-time decision’ for purposes 
of clause (i). 
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138 
‘‘(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 
subparagraph (F)) approved during 
the previous plan year by the plan in 
an initial determination and the per-
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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 
such plan year that were approved 
(categorized by each item and serv-
ice). 
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‘‘(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, cat-
egorized by each applicable item and 
service and categorized 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-
cial intelligence technology, machine- 
learning technology, clinical decision- 
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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 
which, during a surgical or medical 
procedure involving the furnishing of 
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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. 
‘‘(XIII) Such other information 
as the Secretary determines appro-
priate. 
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‘‘(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-
minations with respect to prior au-
thorization requests for an item or 
service. 
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‘‘(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 
‘‘(ii) access to such criteria to enroll-
ees in accordance with subparagraph 
(A)(ii)(III). 
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145 
‘‘(D) PUBLICATION
OF
INFORMATION.— 
The Secretary shall publish 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. 
‘‘(F) SPECIFIED REQUEST DEFINED.—For 
purposes of this paragraph, the term ‘specified 
request’ means a prior authorization request 
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146 
made with respect to an applicable item or serv-
ice. 
‘‘(4) ENROLLEE
PROTECTION
STANDARDS.— 
For purposes of paragraph (1)(A)(ii), with respect 
to the use of prior authorization by Medicare Advan-
tage plans for applicable items and services, the en-
rollee protection standards specified in this para-
graph are— 
‘‘(A) the adoption of transparent prior au-
thorization programs developed in consultation 
with enrollees and with providers and suppliers 
with contracts in effect with such plans for fur-
nishing such items and services under such 
plans; 
‘‘(B) allowing for the waiver or modifica-
tion of prior authorization requirements based 
on the performance of such providers and sup-
pliers in demonstrating compliance with such 
requirements, such as adherence to evidence- 
based medical guidelines and other quality cri-
teria; and 
‘‘(C) conducting annual reviews of such 
items and services for which prior authorization 
requirements are imposed under such plans 
through a process that takes into account input 
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147 
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 cov-
erage criteria. 
‘‘(5) APPLICABLE
ITEM
OR
SERVICE
DE-
FINED.—For purposes 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 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. 
‘‘(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 
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148 
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, 
subject to subsection (o), with respect to prior au-
thorization requests submitted on or after the first 
day of the third plan year beginning after the date 
of the enactment of the øImproving Seniors’ Timely 
Access to Care Act of 2023¿, not later than 24 
hours)’’ after ‘‘72 hours’’. 
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(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, the organization shall 
notify the enrollee (and the physician involved, as 
appropriate) of such determination no later than 7 
days (or such shorter timeframe as the Secretary 
may specify through notice and comment rule-
making, taking into account enrollee and stakeholder 
feedback) after receipt of such request.’’. 
(c) RULE OF CONSTRUCTION.—None of the amend-
ments made by this section may be construed to affect 
the finalization of the proposed rule entitled ‘‘Medicare 
and Medicaid Programs; Patient Protection and Afford-
able Care Act; Advancing Interoperability and Improving 
Prior Authorization Processes for Medicare Advantage Or-
ganizations, Medicaid Managed Care Plans, State Med-
icaid Agencies, Children’s Health Insurance Program 
(CHIP) Agencies and CHIP Managed Care Entities, 
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Issuers of Qualified Health Plans on the Federally Facili-
tated Exchanges, Merit-Based Incentive Payment System 
(MIPS) Eligible Clinicians, and Eligible Hospitals and 
Critical Access Hospitals in the Medicare Promoting 
Interoperability Program’’ published on December 13, 
2022 (87 Fed. Reg. 76238), or application of such rule 
so finalized, for plan years before the third plan year be-
ginning on or after the date of the enactment of this Act. 
SEC. 302. EXTENSION OF CERTAIN DIRECT SPENDING RE-
DUCTIONS. 
Section 251A(6)(D) of the Balanced Budget and 
Emergency Deficit Control Act of 1985 (901a(6)(D)) is 
amended— 
(1) in clause (i), by striking ‘‘; and’’ and insert-
ing a semicolon; 
(2) in clause (ii), by striking ‘‘second 6 months 
in which such order is effective for such fiscal year, 
the payment reduction shall be 0 percent.’’ and in-
serting ‘‘2 month period beginning on the day after 
the last day of the period described in clause (i) in 
which such order is effective for such fiscal year, the 
payment reduction shall be 1.5 percent; and’’; and 
(3) by adding at the end the following new 
clause: 
VerDate Sep 11 2014 
22:59 Jul 24, 2023
Jkt 039200
PO 00000
Frm 00150
Fmt 6652
Sfmt 6201
E:\BILLS\H4822.IH
H4822
kjohnson on DSK79L0C42PROD with BILLS