Sponsors (72)
Official title: 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 Roger Wayne Marshall · Last progress May 20, 2025
The bill improves transparency, oversight, and speed of Medicare Advantage prior authorizations—helping beneficiaries and providers get care sooner—but creates administrative and IT costs, privacy concerns, and automation-related denial risks that may shift burdens or harm access without careful implementation.
Medicare beneficiaries and their providers will get clearer, more transparent prior-authorization rules and access to the criteria and documentation requirements used by MA plans, making coverage decisions easier to understand and contest.
Patients (particularly those with chronic conditions) will experience faster, more standardized prior-authorizations through secure electronic requests, which can reduce delays in care and speed treatment decisions.
Taxpayers and beneficiaries will gain stronger oversight because public reporting and reviews by MedPAC/GAO increase accountability and can drive improvements in MA prior-authorization practices.
Medicare beneficiaries, hospitals, and providers may face higher costs if MA plans and providers incur administrative expenses implementing standardized electronic prior authorization and pass those costs along through premiums or network changes.
Medicare beneficiaries and patients could face wrongful or accelerated denials if MA plans deploy automated decision-support or AI without sufficiently robust oversight and safeguards.
Small provider practices and some hospitals will need to invest in new IT or interfaces because exclusion of fax and proprietary portals forces transition to standardized electronic systems, causing short-term disruption and resource strains.
Based on analysis of 2 sections of legislative text.
Requires Medicare Advantage plans to report detailed prior-authorization data and to implement HHS-standard electronic prior authorization with enrollee protections.
Requires Medicare Advantage plans to publish detailed data about prior authorization use and outcomes and to implement secure electronic prior authorization systems with enrollee protections. Plans must meet transparency rules for plan years starting on or after January 1, 2027, and must implement electronic prior authorization and protection standards for plan years starting on or after January 1, 2028. The bill defines technical standards for electronic transmissions, excludes noncompliant fax and proprietary portals, requires annual reporting to the Secretary of HHS on approvals, denials, appeals, decision times, and use of decision-support technologies, and creates requirements designed to protect enrollees during the prior authorization process.