Improving Seniors’ Timely Access to Care Act of 2025
- Sponsor
- Sen. Marshall, Roger [R-KS]
- Committees
- Finance Committee (primary)
- Last action
- May 20, 2025
Bottom line
The bill aims to streamline prior authorization processes in Medicare Advantage, improve patient access to care, and increase accountability for MA plans through electronic systems, data transparency, and stronger enrollee protections.
What it actually does
This bill amends the Social Security Act to establish new requirements for Medicare Advantage (MA) plans regarding the use of prior authorization. It mandates the implementation of electronic prior authorization programs, enhances transparency through detailed data reporting to the Secretary of Health and Human Services, and sets enrollee protection standards. Additionally, it grants the Secretary authority to establish specific timeframes for MA plans to respond to prior authorization requests, including expedited and 'real-time' decisions.
Proponents argue
Supporters argue that this legislation is crucial for reducing unnecessary delays in patient care and alleviating the significant administrative burden faced by healthcare providers. They contend that by standardizing electronic prior authorization and increasing transparency, the bill will ensure seniors receive timely access to medically necessary services while allowing for better oversight of Medicare Advantage plans.
Opponents contend
While broad bipartisan support suggests minimal direct opposition to the bill's core intent, some critics or industry stakeholders may raise concerns about the administrative and financial burden on Medicare Advantage plans to implement new electronic systems and extensive reporting requirements. They might argue that these costs could potentially be passed on to beneficiaries or impact plan flexibility.
The bill is relatively short and clearly structured, making it accessible for an informed reader to understand its provisions within a reasonable timeframe.
Section 2(a), new SSA 1852(o)(2)
Mandating Electronic Prior Authorization Programs
This provision requires Medicare Advantage plans to establish secure electronic prior authorization programs for applicable items and services, starting January 1, 2028. It explicitly excludes faxes, proprietary payer portals not meeting Secretary-specified standards, or electronic forms from being considered valid electronic transmissions, emphasizing the need for standardized, interoperable electronic systems.
Supporters argue
Proponents argue that electronic prior authorization will significantly streamline a currently cumbersome process, leading to faster approvals, fewer delays in patient care, and reduced administrative waste for both providers and plans. They emphasize that excluding faxes and non-standard portals ensures genuine interoperability and efficiency.
Critics contend
While the concept of electronic prior authorization is widely supported, some MA plans may argue that the specific technical requirements and the timeline for implementation could pose significant financial and operational challenges, especially for smaller plans or those with legacy IT systems.
Tradeoffs
The provision balances the desire for modern, efficient healthcare administration with the potential costs and technical hurdles for Medicare Advantage plans to upgrade their systems to meet new, stringent electronic standards.
Section 2(a), new SSA 1852(o)(3)
Enhanced Transparency and Data Reporting Requirements
Beginning January 1, 2027, this provision requires Medicare Advantage plans to annually submit detailed data to CMS, including lists of services requiring prior authorization, approval/denial rates (initial and on appeal), use of AI in decisions, and average processing times. Plans must also provide prior authorization criteria to providers and enrollees, and CMS must publish this information publicly.
Section 2(a), new SSA 1852(o)(4)
Establishing Enrollee Protection Standards
Effective January 1, 2028, this provision mandates that Medicare Advantage plans adopt transparent prior authorization programs developed with input from enrollees and providers. It requires plans to allow for waivers or modifications of prior authorization requirements based on provider performance and to conduct annual reviews of services subject to prior authorization, considering data and stakeholder input.
Section 2(b), amending SSA 1852(g)
Empowering Secretary to Set Prior Authorization Response Timeframes
This section amends existing law to grant the Secretary of Health and Human Services the authority to establish specific timeframes, such as 24 hours, for Medicare Advantage plans to respond to prior authorization requests. This includes requests for expedited determinations, 'real-time decisions' for routinely approved items, and any other prior authorization requests.
This subclause explicitly states that for the purpose of the electronic prior authorization program, 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.
Section 2(a), new SSA 1852(o)(2)(B)(i)
Why it matters:This is standard legislative practice to define technical terms precisely, ensuring that the intent of 'electronic' is not circumvented by older or non-standard technologies.
Case for: Supporters argue this is crucial to ensure genuine modernization and interoperability, preventing plans from using outdated or proprietary systems that do not meet the spirit of electronic standardization, thereby truly reducing administrative burden.
Case against: No specific opposition is typically raised against this technical clarification, as it aligns with the goal of modernizing healthcare transactions. However, some plans might face higher costs if their current 'electronic' solutions rely on these excluded methods.
Estimated impact: This clarification will force all Medicare Advantage plans to adopt truly standardized and interoperable electronic prior authorization systems, impacting their IT infrastructure and workflow.
This subclause mandates that the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) submit a report by January 1, 2028, that defines 'real-time decision,' details a process for real-time decisions for routinely approved items and services, and analyzes the impact of automation and AI on patient access.
Section 2(a), new SSA 1852(o)(6)(B)(ii)
Why it matters:This is standard legislative practice for requiring agencies to study and report on complex issues, setting the stage for future policy or regulatory actions.
Case for: Proponents argue that this report is critical for future-proofing prior authorization reform, ensuring that policy keeps pace with technological advancements like AI and machine learning, and that these technologies are used responsibly to benefit patients, especially in rural and low-income communities.
Case against: No specific opposition is typically raised against requiring agency reports. However, some might argue that the timeline is ambitious given the complexity of defining 'real-time decisions' and assessing AI impacts.
Estimated impact: This report will lay the groundwork for potential future regulations or guidelines on automated prior authorization, significantly influencing how MA plans utilize advanced technologies.