A group of lawmakers that has been pushing for Medicare Advantage prior authorization reforms applauded the rule CMS finalized Jan. 17 but said Congress must now "cement these gains into law."
Beginning primarily in 2026, certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.
The rule also requires affected payers to implement a Health Level 7 Fast Healthcare Interoperability Resources standard application programming interface to support electronic prior authorization.
The lawmakers said that "while these regulations could have gone further, they will help bring the antiquated prior authorization system into the 21st century with commonsense changes like a streamlined approval process and increased transparency," according to a Jan. 17 news release from Pennsylvania Rep. Mike Kelly's office.
To make these gains permanent, the lawmakers are calling for the passage of the Improving Seniors' Timely Access to Care Act, which passed the House in 2022 but did not make it through the Senate. The bill was reintroduced in 2023 and passed out of the House Ways and Means Committee in July.
Among other policies, the bill would establish an electronic prior authorization process and require Medicare Advantage plans to report to CMS the extent of their use of prior authorization and the rate of approvals or denials. It would also require HHS to develop a process for "real-time decisions" on items and services that are routinely approved.