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Congress reintroduces CMA-supported legislation to reform prior authorization

June 17, 2024
Area(s) of Interest: Advocacy 


Last week, 180 members of Congress, including 135 members of the U.S House of Representatives and 45 senators, introduced a strong, bipartisan bill to improve the prior authorization process for physicians and patients in Medicare Advantage, building on widespread support for prior authorization reform in the last Congress.

Supported by the California Medical Association (CMA), the American Medical Association (AMA) and nearly 400 health organizations, the updated Improving Seniors’ Timely Access to Care Act of 2024 (S. 4532 / H.R. 8702) will streamline health plan bureaucracy to help ensure that Medicare patients can get the care they need, when they need it.

Prior versions of the bill garnered wide, bipartisan support, but stalled because of the high legislative cost of the bill. The updated bill features targeted policy changes to reduce the scored cost of the legislation.

This legislation will also codify in statute many of the reforms contained in the comprehensive prior authorization regulations recently finalized by the Centers for Medicare and Medicaid Service (CMS), which further reduces the cost of the legislation and will ensure another administration cannot rescind the regulations in the future. Specifically, the bill would:

  • Establish an electronic prior authorization process for Medicare Advantage plans, including  standardization of transactions and clinical attachments.
  • Increase transparency around Medicare Advantage prior authorization by requiring plans to list all services subject to prior authorization, the number of services denied and overturned on appeal and the average and median amount of time that elapsed during the previous plan year between the submission of a specified request to the plan and the determination by the plan, by item and service.
  • Clarify CMS authority to establish tighter timeframes for health plan prior authorization decisions, and to implement and enforce real-time prior authorization decisions for routinely approved services,
  • Permit health plans to create gold-card programs.

At the state level, CMA continues to advocate for reforming the broken prior authorization process. This year, CMA is sponsoring SB 516, authored by Senator Nancy Skinner, which removes unnecessary prior authorization requirements; streamlines and modernizes the process for submitting and appealing a prior authorization request; provides transparency and data on health plan actions; and requires a physician of the same or similar specialty to conduct appeals of a prior authorization denial.

 

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