I 
118TH CONGRESS 
1ST SESSION H. R. 4968 
To amend title XVIII of the Social Security Act to exempt qualifying physi-
cians from prior authorization requirements under Medicare Advantage 
plans, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 27, 2023 
Mr. BURGESS (for himself and Mr. VICENTE GONZALEZ of Texas) introduced 
the following bill; which was referred to the Committee on Ways and 
Means, and in addition to the Committee on Energy and Commerce, for 
a period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to exempt 
qualifying physicians from prior authorization require-
ments under Medicare Advantage plans, and for other 
purposes. 
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 ‘‘Getting Over Lengthy 
Delays in Care As Required by Doctors Act of 2023’’ or 
the ‘‘GOLD CARD Act of 2023’’. 
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SEC. 2. EXEMPTION FOR QUALIFYING PHYSICIANS FROM 
PRIOR 
AUTHORIZATION 
REQUIREMENTS 
UNDER MA 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) EXEMPTION
FOR
QUALIFYING
PHYSICIANS 
FROM PRIOR AUTHORIZATION REQUIREMENTS.— 
‘‘(1) IN GENERAL.— 
‘‘(A) EXEMPTION.— 
‘‘(i) IN GENERAL.—In the case of an 
MA organization which utilizes a prior au-
thorization process (as defined in subpara-
graph (B)) with respect to a plan year (be-
ginning with the second plan year begin-
ning after the date of the enactment of 
this subsection), subject to the succeeding 
provisions of this subsection, a physician 
shall be exempt from the prior authoriza-
tion requirements under such process for 
the period of such plan year with respect 
to a specific item, service, or group of simi-
lar services, if during the preceding plan 
year at least 90 percent of prior authoriza-
tion requests submitted to such organiza-
tion by such physician for such item, serv-
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ice, or group were approved by such orga-
nization (including any approval granted 
after an appeal). Such exemption shall con-
tinue to apply with respect to such physi-
cian furnishing such item, service, or group 
of similar services in subsequent plan years 
until the earlier of— 
‘‘(I) the date on which such ex-
emption is revoked under paragraph 
(5); or 
‘‘(II) the date on which such phy-
sician opts out of such exemption 
under paragraph (3)(C). 
‘‘(ii) SPECIAL RULES.—For purposes 
of determining whether a physician quali-
fies for an exemption under clause (i) for 
a plan year for an item, service, or group 
of services, in calculating whether at least 
90 percent of prior authorization requests 
submitted by such physician for such item, 
services, or group during the preceding 
plan year were approved, an MA organiza-
tion shall— 
‘‘(I) subject to subclause (II), 
treat any such claim that was initially 
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denied, subsequently appealed, and 
that remains pending appeal at the 
time of such calculation as having 
been approved if more than 30 days 
have elapsed since the date such ap-
peal was filed; and 
‘‘(II) in the case that, during 
such plan year, such organization 
changed any terms of coverage for 
such item, service, or group of serv-
ices, not take into account any claims 
for such item, service, or group of 
services that were submitted during 
the 90-day period beginning on the 
date of such change. 
‘‘(B) PRIOR
AUTHORIZATION
PROCESS.— 
For purposes of this subsection, the term ‘prior 
authorization process’ means, with respect to 
coverage and payment for items and services 
(other than a covered part D drug) under an 
MA plan offered by an MA organization for a 
plan year, a process under which such organiza-
tion (or a contractor of such organization) de-
termines the medical necessity or medical ap-
propriateness of such items and services prior 
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to the furnishing of such items and services or 
that otherwise requires an individual enrolled 
under such plan, or a provider of services or 
supplier scheduled to furnish items and services 
to such individual, to notify such plan (or such 
contractor) prior to such individual receiving 
such items and services. 
‘‘(2) FREQUENCY OF DETERMINATION OF ELI-
GIBILITY
FOR
EXEMPTION.—An MA organization 
may not evaluate a physician for the exemption de-
scribed in paragraph (1) more than once during any 
plan year. 
‘‘(3) NOTIFICATION REQUIREMENTS.— 
‘‘(A) QUALIFICATION.—An MA organiza-
tion shall, not later than 30 days before the 
first day of each plan year, notify each physi-
cian who qualifies for the exemption described 
in paragraph (1) of such qualification and the 
items, services, or group of similar services with 
respect to which such exemption applies for 
such physician. Nothing in this subparagraph 
shall preclude an MA organization from noti-
fying a physician of such exemption at addi-
tional times throughout a plan year. 
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‘‘(B) REQUESTS UNDER EXEMPTION.—In 
the case of a physician described in subpara-
graph (A) who submits a prior authorization re-
quest to an MA organization for an item or 
service with respect to which an exemption ap-
plies under this subsection, such organization 
shall notify such physician of such exemption as 
soon as possible (but in no case later than 24 
hours after receiving such request). 
‘‘(C) OPT OUT.—Any physician eligible for 
an exemption under paragraph (1) may volun-
tarily waive such exemption by providing writ-
ten notice to the applicable MA organization. 
‘‘(4) REQUIREMENT FOR COVERAGE AND PAY-
MENT.—In the case of a physician who qualifies for 
the exemption described in paragraph (1) with re-
spect to an item, service, or group of similar serv-
ices, an MA organization may not deny or reduce 
coverage and payment for such an item, service, or 
group based on medical necessity or appropriateness 
of care. 
‘‘(5) PROTECTIONS
PERTAINING
TO
REVOCA-
TION OF GOLD CARD.— 
‘‘(A) IN GENERAL.—An MA organization 
may revoke an exemption described in para-
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date of such revocation would 
have been so approved; 
‘‘(II) furnishes such physician 
with a notice of such revocation con-
taining the claim information (includ-
ing identification of specific items and 
services and the individual to whom 
such items and services were fur-
nished) on which the determination 
under subclause (I) was made; and 
‘‘(III) includes in such notice a 
plain-language description of how 
such physician may appeal such deter-
mination in accordance with the rules 
promulgated under subparagraph (B); 
and 
‘‘(ii) the individual conducting the de-
termination under clause (ii)(I)— 
‘‘(I) is a physician; 
‘‘(II) possesses a current and 
nonrestricted license to practice medi-
cine in the State in which the items, 
services, or group of services to which 
such exemption applies were fur-
nished; 
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‘‘(III) is actively engaged in the 
practice of medicine in the same or 
similar specialty as a physician that 
would typically furnish such item, 
service, or group of services; and 
‘‘(IV) is knowledgeable about the 
furnishing of, and has experience fur-
nishing, such item, service, or group 
of services. 
‘‘(B) APPEAL OF EXEMPTION.—The Sec-
retary shall, through notice and comment rule-
making, establish a process under which a phy-
sician may appeal a revocation under subpara-
graph (A). Such process shall ensure that any 
such appeal is resolved within 30 days of such 
appeal being submitted under such process. 
‘‘(C) 
TREATMENT
OF
UNRESOLVED 
CLAIMS.—The 
provisions 
of 
paragraph 
(1)(A)(ii) shall apply with respect to the treat-
ment of claims for a determination made under 
subparagraph (A) in the same manner as such 
provisions apply with respect to the treatment 
of claims for a determination made under para-
graph (1)(A).’’. 
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(b) RULEMAKING.—The Secretary of Health and 
Human Services shall, through rulemaking, specify re-
quirements with respect to the use of prior authorization 
by Medicare Advantage plans for items and services de-
scribed in subsection (o)(1) of section 1852 of the Social 
Security Act (42 U.S.C. 1395w–22), as added by sub-
section (a), to ensure continuity of care for individuals 
transitioning to, or between, coverage under such plans 
in order to minimize any disruption to ongoing treatment 
attributable to prior authorization requirements under 
such plans. 
(c) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Secretary of Health and 
Human Services shall submit to Congress a report on the 
potential impacts of the amendment made by this section 
on communities at high risk for health disparities. 
SEC. 3. OPPORTUNITY FOR PROVIDERS TO PRESENT CASES 
FOR COVERAGE AND PAYMENT DURING THE 
PRIOR AUTHORIZATION PROCESS UNDER MA 
PLANS. 
Section 1852 of the Social Security Act (42 U.S.C. 
1395w–22), as amended by section 2, is further amended 
by adding at the end the following new subsection: 
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‘‘(p) OPPORTUNITY FOR PROVIDERS TO PRESENT 
CASES
FOR COVERAGE
AND PAYMENT DURING
THE 
PRIOR AUTHORIZATION PROCESS.— 
‘‘(1) IN GENERAL.—For plan years beginning 
with the second plan year beginning after the date 
of the enactment of this subsection, any prior au-
thorization 
process 
(as 
defined 
in 
subsection 
(o)(1)(B)) with respect to the coverage and payment 
for items and services (other than a covered part D 
drug) under an MA plan offered by an MA organiza-
tion shall provide, prior to any coverage or payment 
determination with respect to an item or service sub-
ject to such process, for an opportunity for a pro-
vider of services or supplier seeking prior authoriza-
tion to furnish such item or service to discuss with 
a qualifying physician (as defined in paragraph 
(2))— 
‘‘(A) the treatment plan for the individual 
who would be furnished such item or service; 
and 
‘‘(B) the clinical basis on which the organi-
zation will determine coverage or payment for 
such item or service. 
‘‘(2) QUALIFYING
PHYSICIAN
DEFINED.—For 
purposes of paragraph (1), the term ‘qualifying phy-
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sician’ means, with respect to an item or service sub-
ject to a process described in such paragraph that 
a provider of services or supplier is seeking to fur-
nish to an individual, a physician that— 
‘‘(A) possesses a current and nonrestricted 
license to practice medicine in the State in 
which such item or service is to be furnished; 
‘‘(B) is actively engaged in the practice of 
medicine in the same or similar specialty as a 
provider of services or supplier that would typi-
cally furnish such item or service; and 
‘‘(C) is knowledgeable about the furnishing 
of, and has experience furnishing, such item or 
service.’’. 
Æ 
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