Illustration: Gabriella Turrisi/Axios
A prior authorization overhaul for Medicare Advantage beneficiaries may have a stronger chance of passage in this Congress.
- That's because of an expected lower CBO score, a new rule on the issue, and renewed urgency in a post-Chevron environment.
Why it matters: Medicare Advantage beneficiaries have faced delays and denials of care due to the prior authorization process, and health providers routinely list prior authorization issues as one of their top obstacles in doing their jobs.
- A previous version of the bill passed the House unanimously by voice vote in 2022, but then stalled after the CBO issued an estimated cost of $16 billion.
What they're saying: "We addressed some issues that some folks had with the score last time ... which I think was probably the biggest obstacle that we faced," Rep. Suzan DelBene, one of the bill co-leads, told Axios in a Monday phone interview.
- "I feel very strongly that we should be in a great position to get the legislation through," either by itself or attached to other legislation, DelBene added.
- Rep. Mike Kelly, another co-sponsor, also told Axios last week that he was working with Energy and Commerce member Rep. Larry Bucshon to get more members on the bill, so they can push Republican leadership for another floor vote.
What's inside: The Improving Seniors' Timely Access to Care, which was reintroduced in both chambers of Congress in June, would require Medicare Advantage plans to establish a standard electronic prior authorization system beginning in 2027.
- It builds on a Biden administration prior authorization final rule issued in January that requires streamlining and sharing information within existing electronic prior authorization systems and issuing coverage decisions within a certain time frame.
- The legislation would also implement transparency requirements for Medicare Advantage plans to report on the numbers of prior authorization requests that were approved, denied and appealed.
- Unlike the 2022 version, the new bill doesn't mandate the establishment of a real-time decision making process for routine services or require a 24-hour response time for urgent requests.
Those two changes are intended to reduce the estimated CBO cost of the bill down to zero, DelBene told Axios.
- An informal CBO scoring after CMS issued its new prior authorization rule this year had the bill still costing about $4 billion, said Anders Gilberg, senior vice president for government affairs for the Medical Group Management Association. That's down from the original $16 billion.
- Congress is still awaiting the official CBO score on the revamped bill. But Gilberg predicted the new tweaks should drop it down lower.
Between the lines: There's also increased urgency after the Supreme Court's Chevron decision last week, with health care organizations and lawmakers saying they need to get this bill passed to essentially codify the CMS rule.
- The current lack of Chevron deference "is another reason why it's important for us to put legislation in place to make sure it's very clear" that Congress supports the CMS changes, said DelBene.
- "Why I think this is the year for the bill, is No. 1, the Supreme Court's decision on Chevron," said Peggy Tighe, a health lobbyist and legislative counsel to the Regulatory Relief Coalition.
- Codifying the rule would leave "no question of what exactly we're asking the agency to do."
What's next: The House Ways and Means and Energy and Commerce committees could mark up the legislation to try to get it to the House floor again to push pressure for the Senate to take it up.
- But lobbyists said they see an end-of-year bill as the most likely package for it to hitch a ride on, though a lot will be dependent on the outcome of the presidential election.
