Congress seeks to keep the momentum going on improvements to prior authorization

Members of Congress are revitalizing efforts to pass legislation that would streamline prior authorization in Medicare Advantage (MA).

A bipartisan, bicameral group of legislators reintroduced the Improving Seniors’ Timely Access to Care Act, a bill that unanimously passed the House in September 2022 but did not receive a vote in the Senate.

One obstacle at the time was a projection by the Congressional Budget Office that the bill would lead to an increase in federal expenditures of more than $16 billion over 10 years, stemming from an expected increase in healthcare utilization. The latest iteration of the bill is intended to temper that concern by removing explicit provisions regarding the turnaround time for prior authorization decisions.

Changes already on tap

In a move that arguably renders the legislation less urgent than it was two years ago, CMS early this year finalized regulations with core provisions that mirror and build on the 2022 version of the bill.

Among the key aspects of the regulations are time limits of 72 hours for prior authorization decisions about expedited requests and seven calendar days for standard requests, beginning in 2026 for plans in federal healthcare programs. (The deadline in the 2022 version of the bill was 24 hours for expedited requests.)

The new legislation addresses the timeliness of prior authorization decisions by granting HHS authority to establish time frames — something the department already did in the regulations. By essentially shifting the imposition of specific limits from the legislative to the regulatory sphere, Congress can avoid much of the concern over the bill’s budgetary impact.

The legislation would codify many of the regulatory provisions in law for MA and ensure they are not subject to change from one presidential administration to the next. It also could make the provisions less susceptible to possible legal challenges by health plans. That issue could be moot, given that segments of the insurance lobby, such as AHIP, have announced their support for the regulations.

A narrower focus

Unlike the 2024 regulations, the legislation addresses prior authorization only in MA and makes no mention of Medicaid or the Affordable Care Act’s federally operated marketplaces.

In a written statement on the new bill, the Medical Group Management Association (MGMA) noted its constituents view prior authorization in MA as “substantially more burdensome” compared with commercial insurance and Medicaid.

The bill mirrors the regulations in its requirement, starting in 2027, for an electronic prior authorization program that will be designed to speed up requests and responses between MA plans and providers. Proprietary payer portals would not qualify unless they meet designated technical standards as established by HHS.

The regulations have a similar requirement for MA, Medicaid and the ACA marketplaces. And the 72-hour and seven-day regulatory caps on prior authorization decisions are set to apply to MA, Medicaid and the Children’s Health Insurance Program, while ACA marketplace plans must adhere to the same time limit for expedited requests and a 15-day limit for standard requests.

Shedding light on prior authorization

The bill appears to go farther than the regulations in its transparency-related requirements.

Starting in 2026, MA health plans would need to annually report a comprehensive array of prior authorization metrics to HHS, which would be required to post the information on a publicly accessible website (the regulations require payers to post most of the same data on their own websites).

“By requiring MA plans to publicly reveal what services are subject to prior authorization, how many are approved and how long on average they take to approve, this legislation will drive plan accountability,” the MGMA wrote in its statement.

Plans also would need to make available specific information to providers and enrollees. For example, providers seeking to contract with the plan would have access to a list of all items and services subject to prior authorization, along with the policies and procedures that determine decisions.

After contracting with an MA plan, providers would be able to see the plan’s prior authorization criteria, including an itemized list of the documentation to be submitted. Plan enrollees would have access to the criteria as well.

Eyeing greater upgrades

The legislation is more explicit than the 2024 final rule in attempting to set the stage for a real-time prior authorization system. CMS and the Office of the National Coordinator for Health Information Technology would be charged with investigating how such a process would work for routinely approved items and services.

That initiative also would include consideration of how MA payers’ use of AI and automation affects patients’ access to healthcare, including whether it exacerbates disparities for rural and low-income beneficiaries.