Legislation Reintroduced to Reform Medicare Advantage Plans use of Prior Authorization

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06/18/2024

Legislation Reintroduced to Reform Medicare Advantage Plans use of Prior Authorization

A bipartisan bill, Improving Seniors’ Timely Access to Care Act (S. 4532 / H.R. 8702), has been reintroduced at the federal level to reform the use of prior authorization by Medicare Advantage plans. Both Ohio Senators—Brown and Vance—have co-sponsored the bill as well as congressman Balderson, Carey, Latta and Wenstrup. In total there are 135 U.S. House of Representatives and 45 senators signed on as co-sponsors.

The Act was introduced in the last Congress and passed in the House. The OSMA has joined with the AMA and over 400 other associations to urge passage of this critically needed legislation on behalf of patients and doctors across the country.

“Right now, too many older Americans enrolled in Medicare Advantage are forced to deal with unnecessary delays when seeking out medical treatment,” said Senator Sherrod Brown (D-OH). “We need to update the Medicare Advantage program so it works better, faster, and is more transparent for patients and providers. By requiring private insurance companies to streamline prior authorization processes electronically, we can ensure providers can quickly access the information they need to treat and care for their patients in a timely manner.”

The legislation attempts to reform several aspects of the prior authorization process—specifically the bill would:

Establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments.
Increase transparency around MA prior authorization requirements and its use.
Clarify CMS’ authority to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests.
Expand beneficiary protections to improve enrollee experiences and outcomes.
Require HHS and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.

This effort to reform the prior authorization at the federal level addresses companies not regulated at the state level. In addition to this effort, we also continue to advocate for prior authorization reform at the state level through HB 130 that would create a prior authorization gold card program.