Prior Authorization Relief Act
Sponsored By: Senator Sheldon Whitehouse
Introduced
Summary
Standardizing prior authorization for certain high-cost, clinically supported Medicare Advantage items and Part D drugs would require an audit to identify high-reimbursement, evidence-backed items that face excessive approval steps. It would set a single set of prior authorization rules and forms across Medicare Advantage plans while allowing exemptions for providers in two-sided risk models.
Show full summary
- Medicare Advantage enrollees would get uniform prior authorization rules for selected high-reimbursement procedures and Part D drugs, aiming to streamline approvals for items that now require excessive steps.
- Clinicians and hospitals would use the same prior authorization forms across plans for those items, reducing administrative variation. Providers participating in two-sided risk models, including accountable care organizations, can be exempted from the standardized requirements.
- The Secretary must audit prior authorization rules by Jan 1, 2027 and issue a final rule to standardize requirements by May 1, 2028. Medicare Advantage organizations may request that the exemption not apply so prior authorization continues for chosen items in their plans.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 0 benefits, 0 costs, 1 mixed.
Fewer prior authorizations for Medicare Advantage
If enacted, this bill would change prior authorization rules for some Medicare Advantage enrollees. The Secretary would audit prior authorization by January 1, 2027 to find items, services, and Part D drugs that meet three tests: they are in the top 10 percent of reimbursements, have enough clinical evidence for a standard medical policy, and require an excessive number of prior-authorization steps. By May 1, 2028, the Secretary would issue a final rule to standardize prior-authorization requirements and supplemental forms across all Medicare Advantage plans for those identified items, services, and drugs. Prior authorization would not apply when a provider participates in a two-sided risk model, such as an accountable care organization that shares financial gains and losses. A Medicare Advantage organization could ask the Secretary to keep prior authorization for specific items or drugs for its enrollees.
Sponsors & CoSponsors
Sponsor
Sheldon Whitehouse
RI • D
Cosponsors
There are no cosponsors for this bill.
Roll Call Votes
No roll call votes available for this bill.
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