Prior Authorization Relief Act
Sponsored By: Senator Whitehouse, Sheldon [D-RI]
Introduced
Summary
Standardize prior authorization for select high-cost, evidence-backed items and Part D drugs in Medicare Advantage (MA). This bill would require an audit to identify candidates and a uniform rule across all MA plans, while allowing two-sided risk providers flexibility.
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- Families and enrollees: People in Medicare Advantage plans would get the same prior-authorization rules and forms for items and Part D drugs the audit flags, aiming to reduce inconsistent delays and paperwork.
- Providers and suppliers: Clinicians would use standardized prior-authorization requirements and supplemental forms for those items across plans. Providers in two-sided risk models such as accountable care organizations can be exempted to preserve care-management flexibility.
- Medicare Advantage organizations and plans: A Medicare Advantage organization could request that the two-sided risk exemption not apply to its plan. If that request is granted, prior-authorization requirements would continue to apply for that plan.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 1 benefits, 0 costs, 0 mixed.
Standardize Medicare Advantage prior authorization
If enacted, the HHS Secretary would audit Medicare Advantage prior authorization rules by January 1, 2027. The audit would look for items, services, and Part D drugs that meet three tests. The tests are: (1) the item, service, or Part D drug is in the top 10 percent of reimbursements; (2) there is enough clinical evidence to support a standard medical policy; and (3) prior authorization requires an excessive number of steps. If found, the Secretary would issue a final rule by May 1, 2028 to standardize prior authorization steps and supplemental forms across all Medicare Advantage plans, including MA-PD plans. Standardized rules would not apply when the provider is in a two-sided risk model (including certain ACOs) that is at risk for both gains and losses. An MA organization could ask the Secretary to keep its plan's existing prior authorization rules, and if granted, those rules would continue to apply.
Sponsors & CoSponsors
Sponsor
Whitehouse, Sheldon [D-RI]
RI • D
Cosponsors
Sen. Marshall, Roger [R-KS]
KS • R
Sponsored 4/13/2026
Roll Call Votes
No roll call votes available for this bill.
View on Congress.gov