To amend title XXVII of the Public Health Service Act and title XVIII of the Social Security Act to require health insurance issuers and MA organizations to make publicly available certain information with respect to coverage request rejection.

To amend title XXVII of the Public Health Service Act and title XVIII of the Social Security Act to require health insurance issuers and MA organizations to make publicly available certain information with respect to coverage request rejection.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. Short title.

SEC. 2. Requiring disclosure of certain information with respect to coverage request rejection.

(a) Requirement for health insurance issuers.—

(1) IN GENERAL.—Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended by adding at the end the following new section:

“SEC. 2730. Requiring disclosure of certain information with respect to coverage request rejection.

“(a) In general.—A health insurance issuer offering group or individual health insurance coverage for a plan year shall, not later than 1 year after the last day of each such plan year, submit to the Secretary and make publicly available on a website of the issuer, with respect to such plan year—

“(1) the deidentified information described in subsection (b), disaggregated in accordance with subsection (c), in a consumer-friendly manner that is simple and understandable; and

“(2) a list of all covered items or services that are subject to prior authorization.

“(b) Information described.—For purposes of subsection (a), the information described in this subsection is, with respect to a health insurance issuer offering group or individual health insurance coverage and a plan year, the percentage and number of each of the following:

“(1) Coverage requests denied, in whole or in part, by the issuer on initial review.

“(2) Coverage requests approved by the issuer on initial review.

“(3) Appeals of coverage requests denied by the issuer and any such appeals that resulted in reversal, in whole or in part, of such denials.

“(c) Disaggregation of information.—The information described in subsection (b) shall be disaggregated by—

“(1) the type of coverage request;

“(2) the reason for the denial;

“(3) the process by which denied coverage requests were reviewed, including whether the denial determination was the result of a fully automated review process (such as artificial intelligence), an algorithmic review, or review by an individual;

“(4) the type of covered item or service;

“(5) the time that elapsed between when the coverage request or the appeal of a denial of a coverage request (as applicable) was filed and when the health insurance issuer offering group or individual health insurance coverage reached a determination as to such coverage request or appeal, expressed in days and hours; and

“(6) in the case of an appeal of a denial of a coverage request, whether such appeal was expedited.

“(d) Standards for publication.—The Secretary shall establish standard definitions and reporting formats for the information described in subsection (b) to—

“(1) ensure that such information is accurate, easy to compare, and consumer-friendly; and

“(2) to the greatest extent practicable, ensure that the submission of such information does not require a health insurance issuer offering group or individual health insurance coverage to seek additional information from a health care provider.

“(e) Publication by Secretary.—On an annual basis, the Secretary shall make available on the website of the Department of Health and Human Services the information submitted to the Secretary under subsection (a).

“(f) Definitions.—In this section:

“(1) COVERAGE REQUEST.—The term ‘coverage request’ means—

“(A) a claim for a covered item or service; and

“(B) a prior authorization request for a covered item or service.

“(2) COVERED ITEM OR SERVICE.—The term ‘covered item or service’ means, with respect to a health insurance issuer offering group or individual health insurance coverage, an item or service for which benefits are available under such coverage.”.

(2) EFFECTIVE DATE.—The amendments made by this subsection shall apply with respect to plan years beginning on or after January 1 of the first year beginning after the date of enactment of this subsection.

(b) Requirement for MA organizations.—Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:

“(7) REQUIRING DISCLOSURE OF CERTAIN INFORMATION WITH RESPECT TO COVERAGE REQUEST REJECTION.—

“(A) IN GENERAL.—For plan years beginning on or after January 1 of the first year beginning after the date of enactment of this paragraph, a contract under this section with an MA organization shall require such organization, not later than 1 year after the last day of each such plan year, to submit to the Secretary and make publicly available on a website of such organization, with respect to each MA plan offered by such organization during such plan year—

“(i) the deidentified information described in subparagraph (B), disaggregated in accordance with subparagraph (C), in a consumer-friendly manner that is simple and understandable; and

“(ii) a list of all covered items or services that are subject to prior authorization.

“(B) INFORMATION DESCRIBED.—For purposes of subparagraph (A), the information described in this subparagraph is, with respect to an MA plan offered by an MA organization and a plan year, the percentage and number of each of the following:

“(i) Coverage requests denied, in whole or in part, by the MA organization on initial review.

“(ii) Coverage requests approved by the MA organization on initial review.

“(iii) Appeals of coverage requests denied by the MA organization and any such appeals that resulted in reversal, in whole or in part, of such denials.

“(C) DISAGGREGATION OF INFORMATION.—The information described in subparagraph (B) shall be disaggregated by—

“(i) the type of coverage request;

“(ii) the reason for the denial;

“(iii) the process by which denied coverage requests were reviewed, including whether the denial determination was the result of a fully automated review process (such as artificial intelligence), an algorithmic review, or review by an individual;

“(iv) the type of covered item or service;

“(v) the time that elapsed between when the coverage request or the appeal of a denial of a coverage request (as applicable) was filed and when the MA organization reached a determination as to such coverage request or appeal, expressed in days and hours; and

“(vi) in the case of an appeal of a denial of a coverage request, whether such appeal was expedited.

“(D) STANDARDS FOR PUBLICATION.—The Secretary shall establish standard definitions and reporting formats for the information described in subparagraph (B) to—

“(i) ensure that such information is accurate, easy to compare, and consumer-friendly; and

“(ii) to the greatest extent practicable, ensure that the submission of such information does not require an MA organization to seek additional information from a health care provider.

“(E) PUBLICATION BY SECRETARY.—On an annual basis, the Secretary shall make available on the website of the Department of Health and Human Services the information submitted to the Secretary under subparagraph (A).

“(F) DEFINITIONS.—In this paragraph:

“(i) COVERAGE REQUEST.—The term ‘coverage request’ means—

“(I) a claim for a covered item or service; and

“(II) a prior authorization request for a covered item or service.

“(ii) COVERED ITEM OR SERVICE.—The term ‘covered item or service’ means, with respect to an MA plan, an item or service for which benefits are available under such plan.”.