Valued Voice

On May 20, a group of bipartisan legislators reintroduced the Improving Seniors' Timely Access to Care Act, legislation meant to curb prior authorization (PA) abuse in Medicare Advantage (MA).

The legislation had passed the U.S. House unanimously in 2022 but stalled in the U.S. Senate after the Congressional Budget Office (CBO) estimated its cost at $16 billion. The 2024 version of this legislation scored as cost neutral from CBO due to CMS having finalized rulemaking effectuating certain aspects of the previous legislation to reduce the score by $4 billion. Additionally, the authors decided to remove real-time decision requirements and expedited determinations that had been in the previous iteration of the legislation. While last session's legislation was supported by a super majority of members in the Senate (60) and a majority in the House (232), it failed to pass in a session that was defined by gridlock.

The reintroduced legislation is largely unchanged from last year and will again require a public report on establishing real-time decisions and will clarify CMS' authority to set expedited determinations and establish timelines for certain aspects of the PA process. It will also:

• Establish standardized electronic prior authorizations for MA plans.
• Increase transparency around MA plans' use of PA.
• Expand beneficiary protections.
• Provide a pathway for CMS to institute real-time PA decisions for routinely approved items and services.

Lead Senate author Roger Marshall (R-KS) said he was hopeful legislators had taken care of the major concerns from last session that would allow Congress to quickly pass this legislation. "As a physician, I understand the frustration this arbitrary process is causing health care practices across the country and the headaches it creates for our nurses," said Marshall in his press release announcing the legislation. “With the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, we will streamline prior authorization and help improve patient outcomes and access to quality care,” he added.

WHA joined a group of more than 500 national and state organizations that endorsed it in 2024, including the American Hospital Association. More than 160 organizations (including WHA), 47 senators and 73 house members have already endorsed the reintroduced legislation. "This legislation will help drive health plan accountability by both streamlining the PA process and requiring health insurers to publicly reveal what services are subject to PA, as well as the volumes of denials, appeals, and other unnecessary costs and bureaucracy prior authorization adds to the health care system under Medicare Advantage," said WHA President and CEO Eric Borgerding.

A section-by-section summary of the legislation may be found here. Contact WHA Vice President of Federal and State Relations Jon Hoelter with questions.