Improving Seniors’ Timely Access to Care Act of 2025
- Sponsor
- Rep. Kelly, Mike [R-PA-16]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Jul 15, 2026
Bottom line
This bill aims to streamline and increase transparency in the prior authorization process for Medicare Advantage enrollees and providers.
What it actually does
This bill establishes new requirements for Medicare Advantage (MA) plans regarding prior authorization. It mandates electronic prior authorization programs, sets transparency reporting standards for MA plans, and introduces enrollee protection standards. It also grants the Secretary of HHS authority to set specific timeframes for MA plans to respond to prior authorization requests, including expedited and real-time decisions.
Proponents argue
Supporters argue that the bill will reduce administrative burdens for healthcare providers, improve timely access to medically necessary care for seniors, and increase transparency in MA plan operations. They contend that current prior authorization practices often delay or deny essential services, leading to poorer health outcomes and increased costs in the long run.
Opponents contend
Critics, if any, might argue that the new requirements could increase administrative costs for Medicare Advantage plans, potentially leading to higher premiums or reduced benefits for enrollees. Some might also express concerns about the feasibility of implementing complex electronic systems and standardized data reporting across all plans by the specified deadlines, or that it could limit plans' ability to manage utilization and control costs effectively.
The bill is relatively concise and clearly structured, making it accessible for an informed reader to understand its core provisions and implications within a reasonable timeframe.
Section 2(a), adding new Social Security Act Section 1852(o)(1)(A) and (2)
Establishment of Electronic Prior Authorization Program
Beginning January 1, 2028, Medicare Advantage plans must implement an electronic system for prior authorization requests. This system must allow for the secure electronic transmission of requests and responses, along with supporting documentation. Importantly, faxes, proprietary payer portals that don't meet Secretary's standards, and electronic forms are explicitly excluded from being considered valid electronic transmissions, pushing for standardized, interoperable digital solutions.
Supporters argue
Supporters argue this provision will significantly reduce the time and paperwork associated with prior authorization, allowing providers to focus more on patient care and patients to receive necessary services more quickly. It modernizes an outdated process.
Critics contend
Some MA plans might argue that developing and implementing these robust electronic systems by 2028 will be costly and challenging, potentially requiring significant investment in new technology or upgrades to existing infrastructure, which could ultimately impact plan costs.
Tradeoffs
Balances the desire for administrative efficiency and timely patient care against the potential implementation costs and technical challenges for MA plans.
Section 2(a), adding new Social Security Act Section 1852(o)(1)(B) and (3)
Annual Reporting and Public Disclosure of Prior Authorization Data
Starting January 1, 2027, MA plans must annually submit detailed data to the Secretary of HHS regarding their prior authorization practices. This includes lists of services requiring prior authorization, approval/denial rates (initial and on appeal), use of AI/decision support technology, average response times, and grievances related to prior authorization. This information will be published on a public CMS website, and plans must also provide access to their criteria to providers and enrollees upon request.
Section 2(a), adding new Social Security Act Section 1852(o)(1)(A) and (4)
Standards for Protecting Enrollee Access to Care
Effective January 1, 2028, MA plans must adopt specific standards to protect enrollees. These include developing transparent prior authorization programs in consultation with enrollees and providers, allowing for waivers or modifications of prior authorization requirements for high-performing providers, and conducting annual reviews of services subject to prior authorization based on data and stakeholder input.
Section 2(b), amending Social Security Act Section 1852(g)
Expedited Prior Authorization Decision Timeframes
The bill grants the Secretary of HHS the authority to establish specific timeframes (e.g., 24 hours) for Medicare Advantage plans to respond to prior authorization requests. This applies to expedited determinations, "real-time decisions" for routinely approved items and services, and any other prior authorization requests, overriding the existing 72-hour standard for expedited requests starting from the third plan year after enactment.
The bill explicitly states that a facsimile, a proprietary payer portal that does not meet Secretary-specified standards, or an electronic form shall not be treated as an "electronic transmission" for the purpose of the electronic prior authorization program.
Section 2(a), adding new Social Security Act Section 1852(o)(2)(B)(i)
Why it matters:This is standard legislative practice to clarify technical definitions and prevent loopholes, ensuring the intent of "electronic" is truly digital and standardized, not just a digital version of an old process.
Case for: Supporters argue this is critical to ensure true interoperability and standardization, preventing MA plans from simply digitizing existing inefficient processes (like faxing) or forcing providers to use multiple, non-standardized proprietary portals. It pushes for a more modern and efficient healthcare IT ecosystem.
Case against: Some MA plans might argue that existing proprietary portals, while not fully standardized, are already functional and widely used by providers, and that disallowing them without a clear, immediate replacement could create temporary disruption or increase compliance costs.
Estimated impact: Significant impact on the technical implementation strategy for MA plans and the workflow for providers, potentially accelerating the adoption of truly standardized electronic health information exchange.
Mandates that by January 1, 2028, CMS and the Office of National Coordinator for Health Information Technology (ONC) submit a report to Congress. This report must define "real-time decision," detail a process for real-time decisions for routinely approved items/services, and analyze the impact of automation and AI on patient access, especially for rural and low-income beneficiaries.
Section 2(a), adding new Social Security Act Section 1852(o)(6)(B)(ii)
Why it matters:This is standard legislative practice for gathering data and informing future policy, rather not directly implementing a new program.
Case for: Supporters argue this report is crucial for understanding how advanced technologies like AI are being used in prior authorization and to ensure that these technologies improve, rather than hinder, patient access and equity, particularly for vulnerable populations. It lays the groundwork for future policy.
Case against: No strong case against, as it's an information-gathering mandate. Some might argue it adds to agency workload without immediate policy change.
Estimated impact: Indirect but potentially significant, as it will inform future regulatory actions and policy decisions regarding AI and automation in healthcare.