[Congressional Record Volume 172, Number 43 (Monday, March 9, 2026)]
[Senate]
[Pages S934-S936]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SA 4385. Mr. MARSHALL (for himself and Mr. Warner) submitted an
amendment intended to be proposed by him to the bill H.R. 6644, a bill
to increase the supply of housing in America, and for other purposes;
which was ordered to lie on the table; as follows:
At the appropriate place, insert the following:
SEC. ___. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE
OF PRIOR AUTHORIZATION UNDER MEDICARE ADVANTAGE
PLANS.
(a) Short Title.--This section may be cited as the
``Improving Seniors' Timely Access to Care Act of 2026''.
(b) Prior Authorization Requirements Under Medicare
Advantage Plans.--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 applicable item or service (as defined in paragraph
(5)) during a plan year, such plan shall--
``(A) beginning with plan years beginning on or after
January 1, 2028--
``(i) establish the electronic prior authorization program
described in paragraph (2); and
``(ii) meet the enrollee protection standards specified
pursuant to paragraph (4); and
[[Page S935]]
``(B) beginning with plan years beginning on or after
January 1, 2027, meet the transparency requirements specified
in paragraph (3).
``(2) Electronic prior authorization program.--
``(A) In general.--For purposes of paragraph (1)(A), the
electronic prior authorization program described in this
paragraph is a program that provides for the secure
electronic transmission of--
``(i) a prior authorization request from a provider or
supplier to a Medicare Advantage plan with respect to an
applicable item or service to be furnished to an individual
and a response, in accordance with this paragraph, from such
plan to such provider or supplier; and
``(ii) any supporting documentation relating to such
request or response.
``(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.--An electronic transmission described in
subparagraph (A) shall comply with applicable technical
standards and other requirements to promote the
standardization and streamlining of electronic transactions
adopted by the Secretary.
``(3) Transparency requirements.--
``(A) In general.--For purposes of paragraph (1)(B), the
transparency requirements specified in this paragraph are,
with respect to a Medicare Advantage plan, the following:
``(i) The plan, annually and in a manner specified by the
Secretary, shall submit to the Secretary the following
information:
``(I) A list of all applicable items and services that were
subject to a prior authorization requirement under the plan
during the previous plan year.
``(II) The percentage and number of specified requests (as
defined in subparagraph (F)) approved during the previous
plan year by the plan in an initial determination and the
percentage and number of specified requests denied during
such plan year by such plan in an initial determination (both
in the aggregate and categorized by each item and service).
``(III) The percentage and number of specified requests
that were denied during the previous plan year by the plan in
an initial determination and that were subsequently appealed.
``(IV) The number of appeals of specified requests resolved
during the preceding plan year, and the percentage and number
of such resolved appeals that resulted in approval of the
furnishing of the item or service that was the subject of
such request, categorized by each applicable item and service
and categorized by each level of appeal (including judicial
review).
``(V) The percentage and number of specified requests that
were denied, and the percentage and number of specified
requests that were approved, by the plan during the previous
plan year through the utilization of decision support
technology, artificial intelligence technology, machine-
learning technology, clinical decision-making technology, or
any other technology specified by the Secretary.
``(VI) The average and the median amount of time (in hours)
that elapsed during the previous plan year between the
submission of a specified 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
were not submitted with the medical or other documentation
required to be submitted by the plan.
``(VII) The percentage and number of specified requests
that were excluded from the calculation described in
subclause (VI) based on the plan's determination that such
requests were not submitted with the medical or other
documentation required to be submitted by the plan.
``(VIII) Information on each occurrence during the previous
plan year in which, during a surgical or medical procedure
involving the furnishing of an applicable item or service
with respect to which such plan had approved a prior
authorization request, the provider or supplier furnishing
such item or service determined that a different or
additional item or service was medically necessary, including
a specification of whether such plan subsequently approved
the furnishing of such different or additional item or
service.
``(IX) A disclosure and description of any technology
described in subclause (V) that the plan utilized during the
previous plan year in making determinations with respect to
specified requests.
``(X) The number of grievances (as described in subsection
(f)) received by such plan during the previous plan year that
were related to a prior authorization requirement.
``(XI) Such other information as the Secretary determines
appropriate.
``(ii) The plan shall provide--
``(I) to each provider or supplier who seeks to enter into
a contract with such plan to furnish applicable items and
services under such 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;
``(II) to each such provider and supplier that enters into
such a contract, access to the criteria used by the plan for
making such determinations and an itemization of the medical
or other documentation required to be submitted by a provider
or supplier with respect to such a request; and
``(III) to an enrollee of the plan, upon request, access to
the criteria used by the plan for making determinations with
respect to prior authorization requests for an item or
service.
``(B) Option for plan to provide certain additional
information.--As part of the information described in
subparagraph (A)(i) provided to the Secretary during a plan
year, a Medicare Advantage plan may elect to include
information regarding the percentage and number of specified
requests made with respect to an individual and an item or
service that were denied by the plan during the preceding
plan year in an initial determination based on such requests
failing to demonstrate that such individuals met the clinical
criteria established by such plan to receive such items or
services.
``(C) Regulations.--The Secretary shall, through notice and
comment rulemaking, establish requirements for Medicare
Advantage plans regarding the provision of--
``(i) access to criteria described in subparagraph
(A)(ii)(II) to providers of services and suppliers in
accordance with such subparagraph; and
``(ii) access to such criteria to enrollees in accordance
with subparagraph (A)(ii)(III).
``(D) Publication of information.--The Secretary shall
publish information described in subparagraph (A)(i) and
subparagraph (B) on a public website of the Centers for
Medicare & Medicaid Services. Such information shall be so
published on an individual plan level and may in addition be
aggregated in such manner as determined appropriate by the
Secretary.
``(E) Medpac report.--Not later than 3 years after the date
information is first submitted under subparagraph (A)(i), the
Medicare Payment Advisory Commission shall submit to Congress
a report on such information that includes a descriptive
analysis of the use of prior authorization. As appropriate,
the Commission should report on statistics including the
frequency of appeals and overturned decisions. The Commission
shall provide recommendations, as appropriate, on any
improvement that should be made to the electronic prior
authorization programs of Medicare Advantage plans.
``(F) Specified request defined.--For purposes of this
paragraph, the term `specified request' means a prior
authorization request made with respect to an applicable item
or service.
``(4) Enrollee protection standards.--For purposes of
paragraph (1)(A)(ii), with respect to the use of prior
authorization by Medicare Advantage plans for applicable
items and services, the enrollee protection standards
specified in this paragraph are--
``(A) the adoption of transparent prior authorization
programs developed in consultation with enrollees and with
providers and suppliers with contracts in effect with such
plans for furnishing such items and services under such
plans;
``(B) allowing for the waiver or modification of prior
authorization requirements based on the performance of such
providers and suppliers in demonstrating compliance with such
requirements, such as adherence to evidence-based medical
guidelines and other quality criteria; and
``(C) conducting annual reviews of such items and services
for which prior authorization requirements are imposed under
such plans through a process that takes into account input
from enrollees and from providers and suppliers with such
contracts in effect and is based on consideration of prior
authorization data from previous plan years and analyses of
current coverage criteria.
``(5) Applicable item or service defined.--For purposes of
this subsection, the term `applicable item or service' means,
with respect to a Medicare Advantage plan, any item or
service for which benefits are available under such plan,
other than a covered part D drug.
``(6) Reports to congress.--
``(A) GAO.--Not later than January 1, 2032, the Comptroller
General of the United States shall submit to Congress a
report containing an evaluation of the implementation of the
requirements of this subsection and an analysis of issues in
implementing such requirements faced by Medicare Advantage
plans.
``(B) HHS.--
``(i) The secretary.--Not later than the end of the fifth
plan year beginning after the date of the enactment of this
subsection, and biennially thereafter through the date that
is 10 years after such date of enactment, the Secretary shall
submit to Congress a report containing a description of the
information submitted under paragraph (3)(A)(i) during--
``(I) in the case of the first such report, the fourth plan
year beginning after the date of the enactment of this
subsection; and
``(II) in the case of a subsequent report, the 2 plan years
preceding the year of the submission of such report.
``(ii) CMS.--Not later than January 1, 2028, the Centers
for Medicare & Medicaid Services and the Office of National
Coordinator for Health Information Technology shall submit to
Congress and publish on the internet website of the Centers
for Medicare & Medicaid Services a report that--
``(I) defines the term `real-time decision' and details how
the definition for such term may be updated based on any
technological advances;
``(II) using the data submitted to the Secretary under
paragraph (3)(A)(i), details a process for real-time
decisions for routinely approved items and services for
purposes of
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the electronic prior authorization program described in
paragraph (2); and
``(III) includes an analysis of--
``(aa) items and services that are routinely approved;
``(bb) items and services identified in item (aa) that
could be eligible for real-time decisions;
``(cc) whether establishing real-time decisions for such
items and services could--
``(AA) improve enrollee access to benefits under this part;
``(BB) produce operational efficiencies for providers and
suppliers and Medicare Advantage plans; and
``(CC) reduce health disparities for Medicare Advantage
enrollees in rural and low-income communities; and
``(dd) how determinations of routinely approved items and
services made solely through automation and artificial
intelligence by Medicare Advantage plans impact patient
access, including disparities in access for rural and low-
income beneficiaries.''.
(c) Providing the Secretary Authority To Enforce Timely
Responses for All Prior Authorization Requests Submitted
Under Part C.--Section 1852(g) of the Social Security Act (42
U.S.C. 1395w-22(g)) is amended--
(1) in paragraph (1)(A), by inserting ``and in accordance
with any timeframe established by the Secretary under
paragraph (6)'' after ``paragraph (3)'';
(2) in paragraph (3)(B)(iii), by inserting ``(with respect
to prior authorization requests submitted on or after the
first day of the third plan year beginning after the date of
the enactment of the Improving Seniors' Timely Access to Care
Act of 2026, any timeframe established by the Secretary under
paragraph (6))'' after ``72 hours''; and
(3) by adding at the end the following new paragraph:
``(6) Timeframe for response to prior authorization
requests.--Subject to paragraph (3), the Secretary may
establish, for purposes of an organization determination made
with respect to a prior authorization request for an item or
service to be furnished to an individual, timeframes, such as
24 hours, for the organization to notify the enrollee (and
the physician involved, as appropriate) of such determination
for--
``(A) a request for expedited determination described in
paragraph (3)(A);
``(B) a real time decision for routinely approved items and
services; and
``(C) any other prior authorization request.''.
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