Sponsors (298)
Requires MA plans to report detailed prior‑authorization data starting in 2027 and to implement Secretary‑standard electronic prior authorization by 2028.
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 modernizes and standardizes electronic prior authorization to speed approvals and increase transparency for Medicare enrollees and providers, but it raises implementation and reporting costs that could be passed to beneficiaries and introduces risks from AI-driven denials and metric gaps that may hide real delays.
Medicare beneficiaries will get faster, standardized electronic prior authorization exchanges, reducing wait times for approved care.
Medicare enrollees gain clearer transparency on which items/services require prior authorization and on plan-specific approval/denial rates, helping them choose plans and challenge denials.
Hospitals, health systems, and healthcare workers will have access to prior-authorization criteria and documentation requirements, enabling more complete requests and fewer administrative delays.
Medicare Advantage enrollees may face higher premiums or reduced benefits because plans will incur costs implementing secure electronic prior authorization systems.
Patients with chronic conditions and other Medicare beneficiaries risk inappropriate care delays if AI or decision-support tools lead to automated denials or if oversight of those tools is inadequate.
Medicare Advantage plans and providers will face increased administrative reporting burdens to collect and publicly report detailed prior-authorization and AI-usage data.
Based on analysis of 2 sections of legislative text.
Requires Medicare Advantage plans that use prior authorization to meet new transparency and electronic prior authorization (ePA) rules. Beginning with plan years starting Jan 1, 2027, plans must provide detailed annual data on prior authorization use and decisions; beginning with plan years starting Jan 1, 2028, plans must implement a Secretary‑standard electronic prior authorization system that securely transmits requests, responses, and supporting documentation and meet enrollee protection standards.