ACAAI-endorsed prior authorization legislation reintroduced

ACAAI-endorsed prior authorization legislation reintroduced

On June 12, the Improving Seniors’ Timely Access to Care Act was reintroduced in both the House and Senate. If approved, this bipartisan legislation would codify a recent Medicare final rule that establishes streamlined electronic prior authorization processes for Medicare Advantage plans, Medicaid managed care plans, and ACA plans. The College is listed as one of more than 370 organizations that endorsed the bill ahead of its reintroduction.

While the original bill unanimously passed the House in 2022 and was co-sponsored by a majority of members in the Senate and House of Representatives, it did not pass the Senate that year over concerns about its cost.

Shortly after the bill’s passage failed, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to implement most of the policies from the Improving Seniors’ Timely Access to Care Act; it was finalized in January 2024.

The CMS rule requires impacted payers to adopt a Fast Healthcare Interoperability Resources (FHIR®) -based application programming interface (API) for facilitating “real-time” prior authorization transactions and requires additional transparency about prior authorization documentation requirements.

For purposes of this regulation, “real-time” means a response within seven calendar days for non-urgent requests and within 72 hours for urgent requests. Additionally, impacted health plans will be required to provide a specific reason for denied prior authorization decisions. These policies take effect on Jan. 1, 2026.

In addition, beginning on Jan. 1, 2027, health plans must begin using a new standardized Patient Access API that will communicate prior authorization decisions and provide the documentation requirements for the request.

This policy does not apply to drugs since there already exists a separate timeliness requirement for those prior authorization requests.

While CMS already implemented many of the requirements outlined in the Improving Seniors’ Timely Access to Care Act, future administrations could change the regulations through new rulemaking. Codifying these changes through legislation would require Congress to pass legislation to make changes. Therefore, the advantage of the reintroduced bill is to provide greater certainty about improvements to prior authorization requirements.

It is not clear when or if Congress will pass the bill. A revised cost estimate from the Congressional Budget Office (CBO) shows the bill’s cost will be at or near zero. This will help address the main policy barrier that prevented this bill from passing in the last Congress. However, the CMS final rule also means there is less urgency behind the effort. The Advocacy Council will continue to push for the bill’s passage to ensure these important policies are codified.