Sponsors (309)
Official title: To amend title XVIII of the Social Security Act to establish requirements with respect to the use of prior authorization under Medicare Advantage plans.
Introduced May 20, 2025 by Mike Kelly · Last progress May 20, 2025
The bill standardizes and digitizes Medicare prior authorization to speed approvals and increase transparency for beneficiaries and providers, but it raises compliance and reporting costs, creates administrative burdens, and leaves risks that AI-driven processes or metric exclusions could still delay or deny needed care.
Medicare beneficiaries will get faster prior-authorization decisions through standardized electronic exchanges, reducing wait times for approved care.
Medicare enrollees gain clearer information about which items/services require prior authorization and plan-specific approval/denial rates, improving consumers' ability to choose plans and challenge denials.
Hospitals, health systems, and clinicians get access to prior-authorization criteria and documentation requirements and a standardized electronic process, enabling more complete requests, fewer administrative delays, and potential long-term administrative cost savings.
Medicare Advantage plans will incur costs to implement secure electronic prior-authorization systems and reporting, which may be passed to enrollees through higher premiums or reduced benefits (and ultimately affect taxpayers).
Plans and providers must collect and publicly report detailed prior-authorization and AI-usage data, increasing administrative and compliance burden for plans and health systems.
Requiring disclosure of AI/decision-support use does not eliminate the risk that those tools could enable automated or inappropriate denials if oversight is insufficient, risking unjustified delays or denials of care for patients with chronic conditions.
Based on analysis of 2 sections of legislative text.
Requires Medicare Advantage plans to report detailed prior-authorization data starting 2027 and implement a Secretary‑approved electronic prior authorization system by 2028.
Requires Medicare Advantage plans that use prior authorization to meet new transparency and electronic prior-authorization standards. Beginning in plan years starting January 1, 2027, plans must report detailed prior-authorization data to the federal government; beginning in plan years starting January 1, 2028, plans must implement an electronic prior authorization system that meets Secretary-established technical and enrollee-protection standards. The bill specifies what data plans must submit (items/services subject to prior authorization, approval/denial rates, appeal outcomes, use of AI/decision‑support, and processing times) and sets rules about what counts as electronic transmission. It also requires plans to publish information for enrollees about prior authorization processes and to exclude requests missing required documentation from time-to-decision calculations.