A bill to require private health plans to provide for secure electronic transmission of prior authorization requests for prescription drugs.

Bill: 118-s-4349
Sponsor: full_name: Sen. Marshall, Roger [R-KS]
Introduced: 2024-05-15
Policy area: Health
Latest action: action_date: 2024-05-15
text: Read twice and referred to the Committee on Health, Education, Labor, and Pensions.

Summaries:

tv_txt: II 118th CONGRESS 2d Session S. 4349 IN THE SENATE OF THE UNITED STATES May 15, 2024 Mr. Marshall (for himself, Mr. Luján , Mr. Wicker , Mr. Manchin , and Mr. Whitehouse ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To require private health plans to provide for secure electronic transmission of prior authorization requests for prescription drugs.

1. Electronic prior authorization for prescription drugs (a) PHSA Part D of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–111 et seq. ) is amended by adding at the end the following: 2799A–11. Electronic prior authorization for prescription drugs (a) In general For plan years beginning on or after January 1, 2027, a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide for the secure electronic transmission of— (1) a prior authorization request from the prescribing health care professional for coverage of a prescription drug for a participant, beneficiary, or enrollee in such plan or coverage to such plan or issuer; and (2) a response, in accordance with this section, from such plan or issuer to such professional. (b) Electronic transmission (1) Exclusions For purposes of this section, 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 subsection (a). (2) Standards In order to be treated, for purposes of this section, as an electronic transmission described in subsection (a), such transmission shall comply with technical standards adopted by the Secretary, in consultation with the Secretary of Labor, the Secretary of the Treasury, the National Council for Prescription Drug Programs, other standard-setting organizations as determined appropriate by the Secretary, and stakeholders, including group health plans and health insurance issuers offering group or individual health insurance coverage, health care professionals, and health information technology software vendors. (3) Application Notwithstanding any other provision of law, for purposes of this section, the Secretary may require the use of standards adopted under paragraph (2) in lieu of any other applicable standards for an electronic transmission described in subsection (a) for prescription drugs for a participant, beneficiary, or enrollee described in such subsection. . (b) ERISA (1) In general Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 et seq. ) is amended by adding at the end the following: 726. Electronic prior authorization for prescription drugs (a) In general For plan years beginning on or after January 1, 2027, a group health plan or health insurance issuer offering group health insurance coverage shall provide for the secure electronic transmission of— (1) a prior authorization request from the prescribing health care professional for coverage of a prescription drug for a participant or beneficiary in such plan or coverage to such plan or issuer; and (2) a response, in accordance with this section, from such plan or issuer to such professional. (b) Electronic transmission (1) Exclusions For purposes of this section, 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 subsection (a). (2) Standards In order to be treated, for purposes of this section, as an electronic transmission described in subsection (a), such transmission shall comply with technical standards adopted by the Secretary, in consultation with the Secretary of Health and Human Services, the Secretary of the Treasury, the National Council for Prescription Drug Programs, other standard-setting organizations as determined appropriate by the Secretary, and stakeholders, including group health plans and health insurance issuers offering group health insurance coverage, health care professionals, and health information technology software vendors. (3) Application Notwithstanding any other provision of law, for purposes of this section, the Secretary may require the use of standards adopted under paragraph (2) in lieu of any other applicable standards for an electronic transmission described in subsection (a) for prescription drugs for a participant or beneficiary described in such subsection. . (2) Clerical amendment The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1001 et seq. ) is amended by inserting after the item relating to section 725 the following: Sec. 726. Electronic prior authorization for prescription drugs. . (c) IRC (1) In general Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following: 9826. Electronic prior authorization for prescription drugs (a) In general For plan years beginning on or after January 1, 2027, a group health plan shall provide for the secure electronic transmission of— (1) a prior authorization request from the prescribing health care professional for coverage of a prescription drug for a participant or beneficiary in such plan to such plan; and (2) a response, in accordance with this section, from such plan to such professional. (b) Electronic transmission (1) Exclusions For purposes of this section, 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 subsection (a). (2) Standards In order to be treated, for purposes of this section, as an electronic transmission described in subsection (a), such transmission shall comply with technical standards adopted by the Secretary of Health and Human Services, in consultation with the Secretary of Labor, the National Council for Prescription Drug Programs, other standard-setting organizations as determined appropriate by the Secretary, and stakeholders, including group health plans, health care professionals, and health information technology software vendors. (3) Application Notwithstanding any other provision of law, for purposes of this section, the Secretary may require the use of standards adopted under paragraph (2) in lieu of any other applicable standards for an electronic transmission described in subsection (a) for prescription drugs for a participant or beneficiary described in such subsection. . (2) Clerical amendment The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item: Sec. 9826. Electronic prior authorization for prescription drugs. .