Illustration: Gabriella Turrisi/Axios
A prospective new CBO score could boost chances for action on a long-stalled measure revamping insurer preapprovals in Medicare Advantage.
Why it matters: The legislation would require Medicare Advantage plans to standardize electronic prior authorization systems. Although that could help speed seniors' treatment approvals, it remains a major friction point between providers and insurers.
State of play: Sources tell Axios a preliminary CBO score concludes that an amended version of the Improving Seniors' Timely Access to Care Act's wouldn't result in new spending.
- That could make it easier to include the bill in a year-end package or to pass it by unanimous consent in the Senate or under suspension of the rules in the House.
- A previous version of the bill passed the House by voice vote in 2022 but stalled after the CBO said it would cost $16 billion.
- A prior authorization rule the Biden administration issued this year to reduce red tape in Medicare Advantage helped lower the bill's cost, sources said.
- A majority of lawmakers in both chambers have signed on as sponsors on the bill, as of this fall.
What they're saying: "We're trying to do what we can to get it attached to any other bill. I think it has a chance for unanimous consent even to go through that path," main sponsor Sen. Roger Marshall told Axios.
- "I think with the zero CBO score there's no reason it doesn't get across the finish line. I think we need the Finance Committee to bless it going forward if they're not going to send it through committee, then give us a chance to go through with unanimous consent," he added.
- "God, that there's something in life that's actually zero cost for taxpayers should help," Rep. Mike Kelly, one of the main sponsors in the House, told Axios. "I know we've been trying for a long time, and this bill just makes sense."
The other side: Insurers argue that it's necessary for patients to get preapprovals for procedures and services to prevent costly, unnecessary care.
- The prior authorization bill would require insurers to provide more reporting on their decisions to HHS, which would have the power to set deadlines for insurers to respond to various types of requests.
- The Better Medicare Alliance, a Medicare Advantage advocacy group, supports the bill. AHIP hasn't weighed in.
Inside the room: Multiple sources said that departing physician-lawmakers Brad Wenstrup, Michael Burgess and Larry Bucshon urged Speaker Mike Johnson this week to do prior authorization during the lame duck.
Threat level: Backers of the bill say that the incoming Trump administration could roll back the Biden administration prior authorization rule, sending the effort back to square one.
- The Biden rule requires health insurers to streamline information within existing electronic prior authorization systems and issue coverage decisions within specified times.
- "If they [the Trump administration] wipe out the rule, our bill will cost $16 billion again," said Peggy Tighe, a health lobbyist and legislative counsel to the Regulatory Relief Coalition. "We got all the savings out of the rule.… That's a really important reason to do this now."
The big picture: Physician groups are already asking Congress to delay the nearly 3% Medicare payment cut that's looming in January — a big ask that will require budgetary offsets.
- They maintain prior authorization shouldn't get lost in the shuffle, since it's an administrative burden and a big driver of professional burnout that makes it harder for patients to get needed treatment.
- "The overall goal of this legislation and other efforts like on the regulatory side, is to lessen the burden … on physicians who have to spend an inordinate amount of time dealing with these authorization requests," said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association.
- Prior authorization "is often just another hurdle to jump through … and the person that gets hurt the most is the patient," he added.
