HR 6109
To amend title XVIII of the Social Security Act to establish certain requirements with respect to rates of reversed prior authorization coverage determinations under Medicare Advantage plans.
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- Passed House
- Passed Senate
- To President
- Became Law
Bill overview
This bill changes how Medicare Advantage plans handle prior authorization requests. It sets a limit on how often these plans can initially deny coverage and then reverse that decision. If a plan exceeds this limit, the government can terminate its contract with the plan. The bill focuses on ensuring that plans appropriately reconsider prior authorization requests.
Key provisions
- Establishes a limit of 25% for reversed prior authorization coverage determinations.
- Defines ‘reversed prior authorization coverage determination’ as a coverage decision reconsidered and reversed.
- Allows the Secretary to terminate a Medicare Advantage plan’s contract if it exceeds the reversal rate.
- Requires plans to appropriately reconsider prior authorization requests.
- Sets a threshold for determining if a plan exceeds the allowable rate.
- Addresses the process for reconsideration and appeals of prior authorization denials.
- Specifies that the Secretary can determine if a plan is failing to appropriately reconsider prior authorizations.
- Clarifies the definition of ‘prior authorization coverage determination’.
Who is affected
- Medicare Advantage Plans
- Medicare Beneficiaries
- Centers for Medicare & Medicaid Services (CMS)
- Healthcare Providers
- Insurance Companies
Notable changes
- Introduces a quantitative limit on the rate of reversed prior authorization coverage determinations.
Sponsors
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Primary sponsor
Cosponsors
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119th CONGRESS — 1st Session
H. R. 6109
IN THE HOUSE OF REPRESENTATIVES
A BILL
To amend title XVIII of the Social Security Act to establish certain requirements with respect to rates of reversed prior authorization coverage determinations under Medicare Advantage plans.
Section 1857 of the Social Security Act (42 U.S.C. 1395w–27) is amended—
in subsection (e), by adding at the end the following new paragraph:
In the case of a Medicare Advantage plan that imposes any prior authorization requirement with respect to items or services furnished during a plan year beginning on or after the date that is 1 year after the date of the enactment of this paragraph, if the Secretary determines that such plan exceeds the allowable rate of reversed prior authorization coverage determinations under subparagraph (B) with respect to such plan year, the Secretary shall terminate the contract with respect to the offering of such plan under this section.
greater than 25 percent of prior authorization coverage determinations made during such plan year initially deny coverage and are later—
reconsidered and reversed pursuant to section 1852(g)(2); or
appealed and reversed pursuant to section 1852(g)(5); or
the Secretary determines that—
significantly fewer prior authorization coverage determinations made during such plan year that are reconsidered pursuant to section 1852(g)(2) are reversed, as compared to the number of such determinations made during the previous plan year that are so reconsidered and reversed; and
prior authorization coverage determinationmeans, with respect to a Medicare Advantage plan, a coverage determination made under section 1852(g) regarding whether an individual enrolled in such plan is entitled to receive an item or service under the prior authorization requirement imposed under such plan with respect to such item or service.
in subsection (h)(1)(A), by inserting except in the case of a termination of a contract due to failure to meet the requirement under subsection (e)(6),
before the Secretary
.