Congress introduces legislation to address prior authorization challenges


  • SGIM supports reintroduction of legislation that streamlines the Medicare Advantage prior authorization process; and
  • Senators introduce new legislation to improve access to prescription drugs that require a prior authorization.

On June 12, the Improving Seniors’ Timely Access to Care Act (H.R.8702/S.4518) was officially reintroduced in both the House and Senate. The bill, which aims to streamline the prior authorization process for items and services under Medicare Advantage, has had strong bipartisan support with 125 original sponsors in the House and 42 original sponsors in the Senate.

The bill unanimously passed the House in the 117th Congress but faced challenges due to its $16 billion Congressional Budget Office (CBO) score. In the interim, the Centers for Medicare & Medicaid Services (CMS) finalized its Interoperability and Prior Authorization rule. With these policies in place, the legislation was revised and the CBO score was reduced to zero. The recently reintroduced legislation further streamlines the prior authorization process under Medicare Advantage.

Specifically, the bill would do the following:

Establish an electronic prior authorization (e-PA) process for MA plans including a standardization for transactions and clinical attachments.
Increase transparency around MA prior authorization requirements and their 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 the Department of Health and Human Services and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.
SGIM is proud to have joined over 370 national and state organizations in supporting this bipartisan, bicameral legislation. We hope to see the legislation cross the finish line and enacted into law before the end of this year!

While the Improving Seniors’ Timely Access to Care Act does not apply to the prior authorization of prescription drugs, a group of bipartisan Senators recently introduced separate legislation that aims to streamline access to prescription drugs that require a prior authorization in the private insurance market. Specifically, the Electronic Prior Authorization for Prescription Drugs Act (S.4349) would apply only to exchange plans and employer sponsored plans and require them to provide for secure electronic transmission of prior authorization requests for prescription drugs. We recognize that many SGIM members encounter difficulties with prior authorization requests for medications, not only with private insurance plans but also with Medicare Advantage. Consequently, we will continue to monitor potential opportunities to enhance these processes through legislative efforts or direct collaboration with CMS.

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