Title: Improving Seniors’ Timely Access to Care Act of 2019
Policy area: Health

Summary:
Improving Seniors' Timely Access to Care Act of 2019
This bill establishes several prohibitions, requirements, and standards relating to prior authorization processes under Medicare Advantage (MA) plans.
Specifically, the bill prohibits MA plans from instituting additional prior authorization requirements for surgeries (including related items) that are furnished to a patient during other surgeries for which prior authorization was not required or was already received.
Additionally, MA plans must (1) establish an electronic prior authorization program that meets specified standards, including the ability to provide real-time decisions in response to requests for items and services that are routinely approved; (2) annually publish specified prior authorization information, including the percentage of requests approved and the average response time; and (3) meet other standards, as set by the Centers for Medicare & Medicaid Services, relating to the quality and timeliness of prior authorization determinations.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3107 Introduced in House (IH)]

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116th CONGRESS
  1st Session
                                H. R. 3107

     To amend title XVIII of the Social Security Act to establish 
   requirements with respect to the use of prior authorization under 
           Medicare Advantage plans, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              June 5, 2019

Ms. DelBene (for herself, Mr. Kelly of Pennsylvania, Mr. Marshall, and 
  Mr. Bera) 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 committee concerned

_______________________________________________________________________

                                 A BILL


 
     To amend title XVIII of the Social Security Act to establish 
   requirements with respect to the use of prior authorization under 
           Medicare Advantage plans, and for other purposes.

    Be it enacted by the Senate and House of Representatives 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 2019''.

SEC. 2. SENSE OF CONGRESS.

    It is the sense of Congress that--
            (1) use of prior authorization should be streamlined 
        through electronic transmissions for coverage of covered 
        services for individuals enrolled in federally funded programs 
        such as Medicare, Medicaid, and federally contracted managed 
        care plans to improve patient access to medically appropriate 
        services and reduce administrative burden through automation 
        informed by clinical decision support;
            (2) there should be increased transparency for 
        beneficiaries and providers and increased oversight by the 
        Centers for Medicare & Medicaid Services on the processes used 
        for prior authorization; and
            (3) prior authorization is a tool that can be used to 
        responsibly prevent unnecessary care and promote safe and 
        evidence-based care.

SEC. 3. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR 
              AUTHORIZATION UNDER MEDICARE ADVANTAGE PLANS.

    (a) In General.--Section 1852 of the Social Security 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 benefit, such plan shall, beginning with the first plan 
        year beginning on or after the date of the enactment of this 
        subsection--
                    ``(A) comply with the prohibition described in 
                paragraph (2);
                    ``(B) establish the electronic prior authorization 
                program described in paragraph (3);
                    ``(C) meet the transparency requirements specified 
                in paragraph (4); and
                    ``(D) meet the beneficiary protection standards 
                specified pursuant to paragraph (5).
            ``(2) Prohibition on prior authorization with respect to 
        certain items and services.--A Medicare Advantage plan may not 
        impose any additional prior authorization requirement with 
        respect to any surgical procedure or otherwise invasive 
        procedure (as defined by the Secretary), and any item furnished 
        as part of such surgical or invasive procedure, if such 
        procedure (or item) is furnished during the peroperative period 
        of a procedure for which--
                    ``(A) prior authorization was received from such 
                plan before such surgical or otherwise invasive 
                procedure (or item furnished as part of such surgical 
                or otherwise invasive procedure) was furnished; or
                    ``(B) prior authorization was not required by such 
                plan.
            ``(3) Electronic prior authorization program.--
                    ``(A) In general.--For purposes of paragraph 
                (1)(B), the electronic prior authorization program 
                described in this paragraph is a prior authorization 
                process implemented by a Medicare Advantage plan that 
                provides for the secure electronic transmission of--
                            ``(i) a prior authorization request from a 
                        health care professional to such plan with 
                        respect to an item or service to be furnished 
                        to an individual, including such clinical 
                        information as the professional determines 
                        appropriate to support the furnishing of such 
                        item or service to such individual; and
                            ``(ii) a response, in accordance with this 
                        paragraph, from such plan to such professional.
                    ``(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 transmission 
                        described in subparagraph (A).
                            ``(ii) Standards.--
                                    ``(I) In general.--In order to 
                                ensure appropriate clinical outcome for 
                                individuals, for purposes of this 
                                paragraph, an electronic transmission 
                                described in subparagraph (A) shall 
                                comply with technical standards adopted 
                                by the Secretary in consultation with 
                                standard-setting organizations 
                                determined appropriate by the 
                                Secretary, health care professionals, 
                                MA organizations, and health 
                                information technology software 
                                vendors. In adopting such standards, 
                                the Secretary shall ensure that such 
                                transmissions support attachments 
                                containing applicable clinical 
                                information and shall prioritize the 
                                adoption of standards that encourage 
                                integration of the electronic prior 
                                authorization program into established 
                                electronic health record systems.
                                    ``(II) Transaction standard.--The 
                                Secretary shall include in the 
                                standards adopted under subclause (I) a 
                                standard with respect to the 
                                transmission of attachments described 
                                in such subclause, and data elements 
                                and operating rules for such 
                                transmission, consistent with health 
                                care industry standards.
                    ``(C) Real-time decisions.--
                            ``(i) In general.--The program described in 
                        subparagraph (A) shall provide for real-time 
                        decisions (as defined by the Secretary) with 
                        respect to requests identified by the Secretary 
                        pursuant to clause (ii) for a plan year if such 
                        requests contain all information required by an 
                        MA plan to evaluate the criteria described in 
                        paragraph (4)(A)(iii)(II).
                            ``(ii) Identification of requests.--For 
                        purposes of clause (i) and with respect to a 
                        plan year, the Secretary shall identify, not 
                        later than the date on which the initial 
                        announcement described in section 
                        1853(b)(1)(B)(i) for such plan year is required 
                        to be announced, items and services for which 
                        prior authorization requests are routinely 
                        approved.
                            ``(iii) Data collection and consultation 
                        with relevant eligible professional 
                        organizations and relevant stakeholders.--In 
                        identifying requests for a year under clause 
                        (ii), the Secretary shall use the information 
                        described in paragraph (4)(A) (if available) 
                        and shall issue a request for information from 
                        providers, suppliers, patient advocacy 
                        organizations, and other stakeholders.
            ``(4) Transparency requirements.--
                    ``(A) In general.--For purposes of paragraph 
                (1)(C), the transparency requirements specified in this 
                paragraph are, with respect to a Medicare Advantage 
                plan, the following:
                            ``(i) The plan, not less frequently than 
                        annually and at a time and in a manner 
                        specified by the Secretary, shall submit to the 
                        Secretary the following information:
                                    ``(I) A list of all items and 
                                services that are described in 
                                subsection (a)(1)(B) that are subject 
                                to a prior authorization requirement 
                                under the plan.
                                    ``(II) The percentage of prior 
                                authorization requests approved during 
                                the previous plan year by the plan with 
                                respect to each such item and service.
                                    ``(III) The percentage of such 
                                requests that were initially denied and 
                                that were subsequently appealed, and 
                                the percentage of such appealed 
                                requests that were overturned, with 
                                respect to each such item and service.
                                    ``(IV) The average and the median 
                                amount of time (in hours) that elapsed 
                                during the previous plan year between 
                                the submission of such a request to the 
                                plan and a determination by the plan 
                                with respect to such request for each 
                                such item and service, excluding any 
                                such requests that did not contain all 
                                information required to be submitted by 
                                the plan.
                                    ``(V) Such other information as the 
                                Secretary determines appropriate after 
                                consultation with and comment from 
                                stakeholders.
                            ``(ii) The plan shall publish the 
                        information described in clause (i) annually 
                        before open enrollment on a publicly available 
                        website. Such plan shall provide the address of 
                        such website in any enrollment materials 
                        distributed by the plan and shall update such 
                        website in a timely manner.
                            ``(iii) The plan shall provide--
                                    ``(I) along with contract materials 
                                for any provider or supplier who seeks 
                                to participate under the 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 requests; and
                                    ``(II) to each provider and 
                                supplier participating under the plan, 
                                access to the criteria used by the plan 
                                for making such determinations, 
                                including an itemization of the medical 
                                or other documentation required to be 
                                submitted by a provider or supplier 
                                with respect to such a request, except 
                                to the extent that provision of access 
                                to such criteria would disclose 
                                proprietary information of such plan, 
                                as determined by the Secretary.
                    ``(B) 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, the Secretary shall submit to Congress a 
                report describing the information submitted under 
                subparagraph (A)(i) with respect to--
                            ``(i) in the case of the first such report, 
                        the first plan year beginning on or after such 
                        date; and
                            ``(ii) in the case of a subsequent report, 
                        the 2 full plan years preceding the date of the 
                        submission of such report.
            ``(5) Beneficiary protection standards.--The Secretary of 
        Health and Human Services shall, through notice and comment 
        rulemaking, specify standards with respect to the use of prior 
        authorization by MA plans to ensure--
                    ``(A) that such plans adopt transparent programs 
                developed in consultation with providers and suppliers 
                participating under the plans that promote the 
                modification of such requirements based on the 
                performance of such providers and suppliers with 
                respect to adherence to evidence-based medical 
                guidelines and other quality criteria;
                    ``(B) that such plans conduct annual reviews of 
                items and services for which prior authorization 
                requirements are imposed under such plans through a 
                process that takes into account input from 
                participating providers and suppliers and is based on 
                analysis of past prior authorization requests and 
                current clinical criteria;
                    ``(C) 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;
                    ``(D) that such plans make timely prior 
                authorization determinations, provide rationales for 
                denials, and ensure requests are reviewed by qualified 
                medical personnel; and
                    ``(E) that plans assist providers and suppliers in 
                submitting the information necessary to enable the plan 
                to make a prior authorization determination in a timely 
                manner.''.
    (b) Determination Clarification.--Section 1852(g)(1)(A) of the 
Social Security Act (42 U.S.C. 1392w-22(g)(1)(A)) is amended by 
inserting ``(including any decision made with respect to a prior 
authorization request for such service)'' after ``section''.
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