Prior Authorization Relief Act

Bill: 118-s-5612
Sponsor: full_name: Sen. Whitehouse, Sheldon [D-RI]
Introduced: 2024-12-19
Policy area: Health
Latest action: action_date: 2024-12-19
text: Read twice and referred to the Committee on Finance.

Summaries:

tv_txt: II 118th CONGRESS 2d Session S. 5612 IN THE SENATE OF THE UNITED STATES December 19 (legislative day, December 16), 2024 Mr. Whitehouse introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend part C of title XVIII of the Social Security Act to provide for prior authorization reforms under the Medicare Advantage program.

1. Short title This Act may be cited as the Prior Authorization Relief Act . 2. Medicare Advantage program prior authorization reforms (a) Medicare Advantage Section 1859 of the Social Security Act ( 42 U.S.C. 1395w–28 ) is amended by adding at the end the following new subsection: (j) Prior authorization requirements (1) Audit Not later than January 1, 2026, the Secretary shall conduct an audit of prior authorization requirements for items and services furnished, and covered part D drugs prescribed, to enrollees under this part in order to identify the items and services and covered part D drugs that the Secretary determines meet each of the following criteria: (A) Reimbursement for such item or service or covered part D drug under this part is in the top 10 percent of reimbursements for all items and services and covered part D drugs under this part. (B) There is sufficient clinical evidence to establish a standard medical policy for the prior authorization process for such item or service or covered part D drug. (C) Prior authorization for such item or service or covered part D drug requires an excessive number of steps to complete the required protocols. (2) Standardized requirements Not later than October 1, 2026, taking into account the results of the audit conducted under paragraph (1), the Secretary shall promulgate a final rule to standardize the prior authorization requirements (including supplemental forms) for items and services and covered part D drugs identified under paragraph (1) across all Medicare Advantage plans, including MA–PD plans. (3) Exemption from requirements (A) In general Subject to subparagraph (B), if an accountable care organization satisfies the savings requirements under section 1899(d)(1)(B) for a performance year beginning on or after January 1, 2026, in the case of an ACO professional (as defined in section 1899(h)(1)) participating in such ACO with a patient load that includes at least 20 percent of Medicare fee-for-service beneficiaries (as defined in section 1899(h)(2)) assigned to such accountable care organization, the prior authorization requirements for the items and services and covered part D drugs identified under paragraph (1) shall not apply when such items and services are furnished by, or such covered part D drugs are prescribed by, such ACO professional during the succeeding year to an enrollee under this part. (B) Limitation The Secretary shall establish a process under which an MA organization offering a Medicare Advantage plan (including an MA–PD plan) may request that the exemption under subparagraph (A) not apply with respect to items and services and covered part D drugs furnished to enrollees under the plan and that the prior authorization requirements that would otherwise apply under the plan for such items and services and covered part D drugs continue to apply. .