‘‘(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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graph (1) granted with respect to a physician 
for an item, service, or group of similar services 
for a plan year only if— 
‘‘(i) the MA organization— 
‘‘(I) determines that— 
‘‘(aa) less than 90 percent 
of claims submitted by such phy-
sician for such item, service, or 
group during the 90-day period 
ending on the date of such rev-
ocation would have been ap-
proved under the prior authoriza-
tion process employed by such 
plan had such process applied 
with respect to such claims; or 
‘‘(bb) in the case that fewer 
than 10 claims were submitted 
by such physician for such item, 
service, or group during the 90- 
day period ending on the date of 
such revocation, less than 90 per-
cent of the last 10 claims sub-
mitted by such physician for such 
item, service, or group as of the 
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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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