Improving access to timely care for enrollees of Medicare Advantage plans

(a) Reducing timeframes for Medicare Advantage organizations To respond to certain authorization requests (1) Standard organization determinations Section 1852(g)(1) of the Social Security Act (42 U.S.C. 1395w–22(g)(1)) is amended— (A) in subparagraph (A), in the second sentence, by inserting subparagraph (C) and after Subject to; (B) in subparagraph (B), by striking Such a determination and inserting A determination described in subparagraph (A) or (C); and (C) by adding at the end the following new subparagraph: (C) Required timeframes for responses to certain authorization requests (i) In general Subject to clause (ii) and paragraph (3)(B)(iii), the procedure established pursuant to subparagraph (A) by a Medicare Advantage organization offering an MA plan shall provide that in the case of a request made on or after January 1, 2028, for a specified authorization (as defined in clause (iii)) with respect to an individual enrolled under such plan, the Medicare Advantage organization must notify the individual (and the provider of services or supplier involved, as appropriate) of the determination regarding such request as expeditiously as the health condition of the individual requires, but, subject to clause (iv), not later than 72 hours after receipt of the request. (ii) Extensions Subject to clause (iv), a Medicare Advantage organization offering an MA plan may extend the deadline applied under clause (i) or the deadline applied under paragraph (3)(B)(iii)(II), as applicable, with respect to a determination regarding a specified request for an individual enrolled under the MA plan, by up to 7 calendar days if— (I) the individual requests the extension; (II) the extension is needed for purposes of obtaining additional relevant medical evidence from a provider of services or supplier that does not have a contract with the MA organization to furnish items and services to individuals enrolled under the MA plan; or (III) the extension is in the individual’s interest and is justified by reason of extraordinary, exigent, or other nonroutine circumstances that are not within the reasonable control of the MA organization (as determined by the Secretary). (iii) Specified authorization defined For purposes of this part, the term specified authorization — (I) means, with respect to an individual enrolled under an MA plan offered by a Medicare Advantage organization, an authorization of coverage or payment for an item or service through— (aa) a prior authorization or preservice determination of coverage or payment; or (bb) a concurrent determination made while the individual is receiving the relevant item or service; and (II) includes an authorization for a transfer of the individual between hospitals or between a hospital and post-acute care facility. (iv) Secretarial authority With respect to requests for a specified authorization made on or after January 1, 2030, in carrying out clause (i) and (ii) and paragraph (3)(B)(iii)(II), the Secretary may specify through notice and comment rulemaking a deadline other than the deadline specified in the relevant clause or paragraph.. (2) Expedited organization determinations Section 1852(g)(3)(B)(iii) of the Social Security Act (42 U.S.C. 1395w–22(g)(3)(B)(iii)) is amended— (A) by striking Timely response.—In cases described and inserting: Timely reponse.— (I) In general Subject to subclause (II), in cases described; and (B) by adding at the end the following new subclause: (II) Reducing expedited timeframes for responses to certain authorization requests Subject to paragraph (1)(C)(ii), in cases described in clauses (i) and (ii) that are related to an expedited determination for a specified authorization (as defined in paragraph (1)(C)(iii)) for which a request is submitted on or after January 1, 2028, the Medicare Advantage organization shall notify the enrollee (and the physician involved, as appropriate) of the determination under time limitations established by the Secretary. Subject to paragraph (1)(C)(iv), such notification shall be made not later than 24 hours after the receipt of the request for the determination (or receipt of the information necessary to make the determination).. (3) Improved transparency of certain prior authorization information on the MA plan level Beginning with plan years beginning on or after January 1, 2028, in carrying out the provisions of section 422.122(c) of title 42, Code of Federal Regulations (or any successor regulation), the Secretary of Health and Human Services shall— (A) require Medicare Advantage organizations to report prior authorization data described in such section on the plan level and on the Medicare Advantage organization parent level in addition to the contract level; (B) require Medicare Advantage organizations to report prior authorization data described in such section in a manner that allows comparison of such data based on provider and service category; and (C) in addition to making such data publicly available, as described in such section, make such data available in a downloadable format that is accessible for research purposes and oversight and enforcement activities of the Secretary. (b) Real-Time authorization decisions for certain identified services Section 1852(g)(1) of the Social Security Act (42 U.S.C. 1395w–22(g)(1)), as amended by subsection (a), is further amended— (1) in subparagraph (A), in the second sentence, by striking subparagraph (C) and and inserting subparagraphs (C) and (D) and; (2) in subparagraph (B), by striking A determination described in subparagraph (A) or (C) and inserting A determination described in subparagraph (A), (C), or (D); (3) in subparagraph (C)(i), by striking Subject to clause (ii) and inserting Subject to clause (ii), subparagraph (D),; and (4) by adding at the end the following new subparagraph: (D) Real-time authorization decisions for identified services (i) In general The procedure established pursuant to subparagraph (A) shall require that the Medicare Advantage organization has in place a mechanism and process through which, beginning January 1, 2028, the organization provides a real-time determination, in accordance with this subparagraph, in response to any request for a specified authorization (as defined in subparagraph (C)(iii)) that is— (I) made with respect to an item or service identified on the most recent list published pursuant to clause (iii); and (II) submitted through certified EHR technology (as defined in section 1848(o)(4)). (ii) Requirements for real-time mechanism and process The mechanism and process required under clause (i) shall— (I) include real-time tools capable of providing immediate automated approvals; (II) provide for the integration of such tools in a manner that is interoperable with certified EHR technology (as so defined) used by providers of services and suppliers; and (III) enable immediate notification to the provider of services or supplier, as applicable, of determinations, including, in the case of a denial, notification of any additional documentation needed. (iii) Annual publication of list of identified services requiring real-time authorization support For purposes of this subparagraph, for each plan year beginning on or after January 1, 2028, the Secretary shall annually establish through notice and comment rulemaking a list identifying the following items and services: (I) Items and services for which, with respect to the previous plan year, at least 90 percent of requests for a specified authorization were approved across all Medicare Advantage organizations. (II) Items and services that are clinically low-risk and routine, as defined by the Secretary through notice and comment rulemaking. (III) Items and services that the Secretary identifies, according to standards specified by the Secretary through notice and comment rulemaking, as representative of significant service volume and administrative burden for acquiring such a specified authorization. (iv) Improving transparency (I) Quarterly MAO reports to CMS Beginning January 1, 2028, and quarterly thereafter, each Medicare Advantage organization offering an MA plan shall submit to the Secretary (in a form and manner specified by the Secretary) information (presented by provider and service type) regarding real-time determinations made by the organization during the previous quarter pursuant to this subparagraph, including information on— (aa) the number of real-time determinations made during the quarter, and the percentage of all determinations made during the quarter with respect to an item or service identified on the most recent list published pursuant to clause (iii) that were real-time determinations; (bb) the number and percentage of real-time determinations made during such quarter that were approved; (cc) the number and percentage of such determinations that were denied; (dd) the number and percentage of such denied determinations that were appealed; (ee) the number and percentage of such appealed determinations that were overturned; and (ff) the number and percentage of provider complaints regarding the mechanism and process implemented by the Medicare Advantage organization pursuant to this subparagraph. The information submitted pursuant to the previous sentence shall include such information and be provided in such a manner to enable comparison and analysis of such information on the Medicare Advantage organization level, Medicare Advantage parent organization level, and MA plan level. (II) Public availability of information The Secretary shall make information collected under subclause (I) publicly available on the internet website of the Centers for Medicare & Medicaid Services.. (c) Prohibiting certain authorization processes for certain clinically necessary changes and extensions Section 1852(d) of the Social Security Act (42 U.S.C. 1395w–22(d)) is amended by adding at the end the following new paragraph: (7) Prohibition on requiring certain authorizations Beginning January 1, 2028, in the case that a Medicare Advantage organization offering an MA plan provides approval through a specified authorization (as defined in subsection (g)(1)(C)(iii)) for an item or service to be furnished to an individual enrolled in the plan by a provider of services or supplier, if during the course of furnishing such approved item or service the provider of services or supplier determines that a modification, extension, or adjustment to such item or service is clinically necessary, the Medicare Advantage organization may not require a specified authorization (as defined in subsection (g)(1)(C)(iii)) to be requested with respect to such item or service as so modified, extended, or adjusted. Application of the previous sentence shall not limit the authority of the Medicare Advantage organization to require documentation or post-service notification of any such modification, extension, or adjustment.. (d) Improvements to the reconsiderations process Section 1852(g) of the Social Security Act (42 U.S.C. 1395w–22(g)) is amended— (1) in paragraph (2)— (A) in subparagraph (A), by inserting (or, with respect to determinations made on or after January 1, 2028, not later than 14 days) after 60 days; and (B) by adding at the end the following new subparagraph: (C) Reconsiderations affirming denials of coverage If a reconsideration affirms (in whole or in part) a denial of coverage (including an adverse organization determination under section 422.590 of title 42, Code of Federal Regulations, or any successor regulation) made on or after January 1, 2028, with respect to an individual enrolled in an MA plan offered by a Medicare Advantage organization, the Medicare Advantage organization shall submit to the independent, outside entity with a contract under paragraph (4) the case file and written explanation of the decision as expeditiously as the individual’s health condition requires, but not later than 14 days after the date the Medicare Advantage organization received the request for the reconsideration.; and (2) in paragraph (4)— (A) by striking coverage denials.—The Secretary shall contract with and inserting: coverage denials.— (A) In general The Secretary shall contract with; and (B) by adding at the end the following new subparagraphs: (B) Requirements In reviewing and resolving pursuant to subparagraph (A) a reconsideration of a determination of a Medicare Advantage organization made on or after January 1, 2028, with respect to an individual enrolled in an MA plan offered by the organization, the independent, outside entity shall comply with each of the following requirements: (i) Notice and opportunity to provide supporting documentation The entity shall— (I) not later than 3 days after the date of receipt of the relevant case file from the Medicare Advantage organization, submit to the individual, the representative of the individual (if applicable), and the provider of services or supplier furnishing (or ordering) the item or service that is the subject of the determination, a notification regarding the opportunity to submit documentation, including medical records, regarding medical necessity; and (II) provide a period of 7 days from the date of receipt of such notification for submission of any such documentation. (ii) Decision timeframe After reviewing and considering all supporting documentation received before the end of the 7-day period described in clause (i)(II), the entity shall issue its decision with respect to such reconsideration as expeditiously as the individual’s health condition requires, but by not later than the applicable number of days specified in subparagraph (C) after the last day of the 7-day period described in clause (i)(II). (C) Applicable number of days For purposes of subparagraph (B)(ii), the applicable number of days specified in this subparagraph is— (i) 14 days, in the case of a request (other than with respect to an expedited reconsideration under paragraph (3)) for coverage of an item or service that is not a drug for which payment may be made under part B; (ii) 7 days, in the case of a request (other than with respect to an expedited reconsideration under paragraph (3)) for coverage of a drug for which payment may be made under part B; (iii) 30 days, in the case of a request (other than with respect to an expedited reconsideration under paragraph (3)) for payment of an item or service; and (iv) 24 hours, in the case of a request with respect to an expedited reconsideration under paragraph (3)..