HR3514-119

What This Bill Does

The Improving Seniors' Timely Access to Care Act of 2025 adds Medicare Advantage prior-authorization requirements to Social Security Act section 1852. Beginning with plan years starting January 1, 2027, plans must meet transparency requirements. They must annually report every item and service subject to prior authorization, approval and denial counts and percentages by item and service, denied requests that are appealed, appeal outcomes by level including judicial review, decisions made through decision-support technology, artificial intelligence, machine learning, clinical decision technology, or other specified technology, average and median decision times, excluded incomplete requests, instances where a provider needed a different or additional service during an approved procedure, descriptions of decision technologies, prior-authorization grievances, and other CMS-specified information. Plans must give contracting providers policy and procedure information, give contracted providers criteria and documentation requirements, and give enrollees criteria on request. CMS must publish plan-level data, MedPAC must report to Congress within three years, and CMS must report biennially for up to 10 years. Beginning with plan years starting January 1, 2028, plans must establish a standards-based electronic prior authorization program; fax, nonstandard proprietary portals, and simple electronic forms do not count. Plans must also meet enrollee protection standards developed with enrollee, provider, and supplier input, allow waiver or modification of prior authorization based on provider performance, and annually review items and services subject to prior authorization. GAO must evaluate implementation by January 1, 2032. CMS and ONC must define real-time decision, publish a process for real-time decisions for routinely approved items and services, and analyze effects on access, provider and plan operations, rural and low-income disparities, and automated or AI-only decisions.

Who Benefits and How

Medicare Advantage enrollees benefit from faster, more transparent prior authorization and access to criteria on request. Physicians and suppliers benefit from standards-based electronic requests, criteria access, and potential waivers for good prior-authorization performance. Rural and low-income beneficiaries benefit if real-time decision analysis reduces access disparities. Health IT vendors benefit from demand for standards-compliant prior authorization exchange tools.

Who Bears the Burden and How

Medicare Advantage plans must build electronic prior authorization, report detailed plan-level data, disclose AI use, and review prior-authorization lists annually. CMS staff must write rules, publish data, enforce transparency, and submit recurring reports. MedPAC must analyze prior authorization data and recommend improvements. GAO and ONC must complete implementation and real-time-decision reports.

Key Provisions

• Requires Medicare Advantage prior-authorization transparency reporting beginning in plan year 2027.
• Requires standards-based electronic prior authorization beginning in plan year 2028.
• Requires reporting on approvals, denials, appeals, overturns, timing, grievances, AI use, and intra-procedure changes.
• Requires plans to disclose criteria and documentation rules to providers and, on request, enrollees.
• Creates enrollee protection standards, provider-performance waivers, and annual prior-authorization reviews.
• Requires CMS publication, MedPAC analysis, GAO implementation review, and CMS-ONC real-time-decision analysis.