vide guidance to Medicare Advantage plans re-
garding— 
‘‘(i) the establishment of criteria de-
scribed in subparagraph (A)(ii)(II) and ac-
cess to such criteria by providers and sup-
pliers in accordance with such subpara-
graph; and 
‘‘(ii) access to such criteria by bene-
ficiaries in accordance with subparagraph 
(A)(ii)(III). 
‘‘(C) 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. 
‘‘(4) BENEFICIARY PROTECTION STANDARDS.— 
The Secretary of Health and Human Services shall, 
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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 providers and suppliers with con-
tracts in effect with such plans for furnishing 
such items and services under such plans that 
allow for the modification of prior authorization 
requirements based on the performance of such 
providers and suppliers with respect to adher-
ence to evidence-based medical guidelines and 
other quality criteria; 
‘‘(B) 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 providers and suppliers with 
such contracts in effect and is based on analysis 
of past prior authorization requests and current 
coverage and clinical criteria; 
‘‘(C) continuity of care for individuals 
transitioning to, or between, coverage under 
such plans in order to minimize any disruption 
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to ongoing treatment attributable to prior au-
thorization requirements under such plans; 
‘‘(D) that such plans make timely prior au-
thorization determinations, provide rationales 
for denials, and ensure requests are reviewed by 
qualified medical personnel; and 
‘‘(E) that such plans provide information 
on the appeals process to the beneficiary when 
denying any request for prior authorization 
with respect to an item or service. 
‘‘(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) REPORT TO CONGRESS.—Not later than 
the end of the second plan year beginning on or 
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 an 
evaluation of the implementation of the requirements 
of this subsection, an analysis of an issues in imple-
menting such requirements faced by Medicare Ad-
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vantage plans, and a description of the information 
submitted under paragraph (3)(A)(i) with respect 
to— 
‘‘(A) in the case of the first such report, 
such second plan year; and 
‘‘(B) in the case of a subsequent report, 
the 2 full plan years preceding the date of the 
submission of such report.’’. 
(b) 
DETERMINATION
CLARIFICATION.—Section 
1852(g)(1)(A) of the Social Security Act (42 U.S.C. 
1395w–22(g)(1)(A)) is amended by inserting ‘‘(including 
any decision made with respect to a prior authorization 
request for such service)’’ after ‘‘section’’. 
Æ 
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