I 
119TH CONGRESS 
1ST SESSION H. R. 3514 
To amend title XVIII of the Social Security Act to establish requirements 
with respect to the use of prior authorization under Medicare Advantage 
plans. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 20, 2025 
Mr. KELLY of Pennsylvania (for himself, Ms. DELBENE, Mr. JOYCE of Penn-
sylvania, Mr. BERA, Ms. VAN DUYNE, Ms. CHU, Mr. CRENSHAW, Ms. 
CLARKE of New York, Mr. MURPHY, Ms. MOORE of Wisconsin, Mr. 
BALDERSON, 
Ms. 
SCHRIER, 
Mr. 
YAKYM, 
Ms. 
SEWELL, 
Mrs. 
HARSHBARGER, Mr. LARSON of Connecticut, Mr. CAREY, Mr. EVANS of 
Pennsylvania, Ms. MALLIOTAKIS, Mr. BEYER, Ms. TENNEY, Ms. 
TOKUDA, Mrs. MILLER
of West Virginia, Ms. STEVENS, Mr. 
FITZPATRICK, Mr. COSTA, Mr. SMUCKER, Ms. PRESSLEY, Mr. LAHOOD, 
Mr. DAVIS of North Carolina, Mr. MEUSER, Mr. POCAN, Ms. SALAZAR, 
Mr. FIELDS, Mr. BACON, Mr. FOSTER, Mr. MANN, Ms. BROWNLEY, Mr. 
CISCOMANI, Mr. CONAWAY, Mr. FINSTAD, Ms. BONAMICI, Mr. SHREVE, 
Ms. NORTON, Mrs. KIGGANS of Virginia, Mr. DELUZIO, Mr. THOMPSON 
of Pennsylvania, Mr. MRVAN, Mr. MOULTON, Mr. CASE, Ms. MCBRIDE, 
Ms. ROSS, Ms. BUDZINSKI, Mr. QUIGLEY, Mr. SORENSEN, Mr. 
MCGARVEY, Ms. DAVIDS of Kansas, Ms. BROWN, Mr. CROW, Mr. 
TORRES of New York, Ms. WASSERMAN SCHULTZ, Mr. STANTON, Mr. 
LEVIN, Mr. KEATING, Ms. JOHNSON of Texas, Mr. VICENTE GONZALEZ 
of Texas, Ms. GOODLANDER, Ms. CRAIG, Mr. GOLDMAN of New York, 
Ms. BARRAGA´N, Ms. BALINT, Mr. RYAN, Ms. HOULAHAN, and Mrs. MIL-
LER-MEEKS) introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on En-
ergy 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 committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to establish 
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requirements with respect to the use of prior authoriza-
tion under Medicare Advantage plans. 
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 2025’’. 
SEC. 2. 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 plan years beginning 
on or after January 1, 2028— 
‘‘(i) establish the electronic prior au-
thorization program described in para-
graph (2); and 
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‘‘(ii) meet the enrollee protection 
standards specified pursuant to paragraph 
(4); and 
‘‘(B) beginning with plan years beginning 
on or after January 1, 2027, meet the trans-
parency 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 or supplier to a Medicare 
Advantage plan with respect to an applica-
ble item or service to be furnished to an in-
dividual and a response, in accordance with 
this paragraph, from such plan to such 
provider or supplier; and 
‘‘(ii) any supporting documentation 
relating to such request or response. 
‘‘(B) ELECTRONIC TRANSMISSION.— 
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‘‘(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 applicable technical 
standards and other requirements to pro-
mote the standardization and streamlining 
of electronic transactions adopted by the 
Secretary. 
‘‘(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 
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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-
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 that were de-
nied during the previous plan year by 
the plan in an initial determination 
and that were subsequently appealed. 
‘‘(IV) 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 
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service and categorized by each level 
of appeal (including judicial review). 
‘‘(V) The percentage and number 
of specified requests that were denied, 
and the percentage and number of 
specified requests that were approved, 
by the plan during the previous plan 
year through the utilization of deci-
sion support technology, artificial in-
telligence technology, machine-learn-
ing technology, clinical decision-mak-
ing technology, or any other tech-
nology specified by the Secretary. 
‘‘(VI) 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. 
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‘‘(VII) The percentage and num-
ber of specified requests that were ex-
cluded from the calculation described 
in subclause (VI) based on the plan’s 
determination that such requests were 
not submitted with the medical or 
other documentation required to be 
submitted by the plan. 
‘‘(VIII) Information on each oc-
currence during the previous plan 
year in which, during a surgical or 
medical procedure involving the fur-
nishing of an applicable item or serv-
ice with respect to which such plan 
had approved a prior authorization re-
quest, the provider or supplier fur-
nishing 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. 
‘‘(IX) A disclosure and descrip-
tion of any technology described in 
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subclause (V) that the plan utilized 
during the previous plan year in mak-
ing determinations with respect to 
specified requests. 
‘‘(X) 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. 
‘‘(XI) 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 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-
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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. 
‘‘(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. 
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‘‘(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). 
‘‘(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-
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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 
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; 
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‘‘(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 
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 January 1, 
2032, the Comptroller General of the United 
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Coordinator for Health Information Tech-
nology shall submit to Congress and pub-
lish on the internet website of the Centers 
for Medicare & Medicaid Services a report 
that— 
‘‘(I) defines the term ‘real-time 
decision’ and details how the defini-
tion for such term may be updated 
based on any technological advances; 
‘‘(II) using the data submitted to 
the 
Secretary 
under 
paragraph 
(3)(A)(i), details a process for real- 
time decisions for routinely approved 
items and services for purposes of the 
electronic prior authorization program 
described in paragraph (2); and 
‘‘(III) includes an analysis of— 
‘‘(aa) items and services 
that are routinely approved; 
‘‘(bb) items and services 
identified in item (aa) that could 
be eligible for real-time decisions; 
‘‘(cc) whether establishing 
real-time decisions for such items 
and services could— 
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‘‘(AA) improve enrollee 
access to benefits under this 
part; 
‘‘(BB) produce oper-
ational efficiencies for pro-
viders and suppliers and 
Medicare Advantage plans; 
and 
‘‘(CC) 
reduce 
health 
disparities for Medicare Ad-
vantage enrollees in rural 
and 
low-income 
commu-
nities; and 
‘‘(dd) how determinations of 
routinely approved items and 
services made solely through au-
tomation 
and 
artificial 
intel-
ligence by Medicare Advantage 
plans impact patient access, in-
cluding disparities in access for 
rural 
and 
low-income 
bene-
ficiaries.’’. 
(b) PROVIDING THE SECRETARY AUTHORITY TO EN-
FORCE TIMELY RESPONSES FOR ALL PRIOR AUTHORIZA-
TION REQUESTS SUBMITTED UNDER PART C.—Section 
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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 any timeframe established by the 
Secretary under paragraph (6)’’ after ‘‘paragraph 
(3)’’; 
(2) in paragraph (3)(B)(iii), by inserting ‘‘(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 Improv-
ing Seniors’ Timely Access to Care Act of 2025, any 
timeframe established by the Secretary under para-
graph (6))’’ after ‘‘72 hours’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(6) TIMEFRAME FOR RESPONSE TO PRIOR AU-
THORIZATION
REQUESTS.—Subject to paragraph 
(3), the Secretary may establish, for purposes of an 
organization determination made with respect to a 
prior authorization request for an item or service to 
be furnished to an individual, timeframes, such as 
24 hours, for the organization to notify the enrollee 
(and the physician involved, as appropriate) of such 
determination for— 
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‘‘(A) a request for expedited determination 
described in paragraph (3)(A); 
‘‘(B) a real time decision for routinely ap-
proved items and services; and 
‘‘(C) any other prior authorization re-
quest.’’. 
Æ 
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