Improving Seniors’ Timely Access to Care Act of 2025
- Bill Number
- S. 1816
- Origin Chamber
- Senate
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-05-20: Read twice and referred to the Committee on Finance.
- Last Updated
- 2026-05-13T11:03:32Z
AI-Generated Summary
Purpose of the Legislation
The Improving Seniors' Timely Access to Care Act of 2025 aims to improve access to healthcare services for Medicare Advantage enrollees by establishing stricter rules for prior authorization—a process where insurers must approve certain medical items or services before they are provided. It focuses on making this process faster, more transparent, and less burdensome, particularly for non-drug items and services covered under Medicare Part C (Medicare Advantage plans).
Key Provisions
- Electronic Prior Authorization Program (Effective January 1, 2028): Medicare Advantage plans must implement a secure electronic system for submitting prior authorization requests, responses, and supporting documents from providers (e.g., doctors or suppliers) to the plan. This excludes faxes, non-standard portals, or simple electronic forms; it must follow standards set by the Secretary of Health and Human Services (HHS) to standardize and streamline processes.
- Transparency Requirements (Effective January 1, 2027): Plans must annually report detailed data to HHS, including:
- Lists of items/services requiring prior authorization.
- Approval/denial rates, appeal outcomes, and use of technologies like AI or machine learning in decisions.
- Average/median response times (in hours) for requests.
- Instances where additional services were needed during procedures despite prior approval.
- Grievances related to prior authorization.
- HHS will publish this data on a public website, at the plan level and potentially aggregated. Plans must also share criteria and documentation requirements with contracted providers and, upon request, with enrollees.
- Enrollee Protection Standards (Effective January 1, 2028): Plans must:
- Develop transparent prior authorization programs with input from enrollees and providers.
- Allow waivers or modifications for high-performing providers (e.g., those following evidence-based guidelines).
- Conduct annual reviews of prior authorization requirements, using past data and stakeholder input to assess coverage criteria.
- Timely Response Requirements: Amends existing law to let the HHS Secretary set specific timeframes (e.g., 24 hours) for plans to respond to prior authorization requests, including expedited cases and "real-time" decisions for routinely approved items/services. This builds on current 72-hour rules for non-expedited requests.
- Definitions:
- Applicable item or service: Any covered benefit under the plan except prescription drugs (Part D).
- Specified request: A prior authorization request for an applicable item or service.
- Real-time decision: Defined by HHS/CMS, with processes for routinely approved services to enable quick approvals.
- Reporting and Oversight:
- Medicare Payment Advisory Commission (MedPAC) to report to Congress within 3 years on prior authorization use, including appeals and recommendations for improvements.
- Government Accountability Office (GAO) report by January 1, 2032, evaluating implementation challenges for plans.
- HHS biennial reports to Congress starting after 5 years, analyzing submitted data.
- CMS and the Office of the National Coordinator for Health Information Technology to report by January 1, 2028, on real-time decisions, routinely approved services, and their potential to improve access, efficiency, and reduce disparities (e.g., in rural or low-income areas).
Significant Changes to Existing Law
- Introduces mandatory electronic prior authorization, replacing or supplementing outdated methods like faxes, to modernize and speed up approvals under Medicare Advantage (Section 1852 of the Social Security Act).
- Adds comprehensive transparency and reporting mandates not previously required, including public disclosure of denial/appeal data and technology use in decisions.
- Enhances enrollee protections by requiring stakeholder input, performance-based waivers, and annual reviews—expanding beyond current basic appeal rights.
- Empowers the HHS Secretary to enforce shorter response times (e.g., 24 hours for certain requests), tightening the existing 72-hour standard for initial determinations (amends Section 1852(g)).
- Excludes Part D drugs from these rules, focusing changes on non-drug services like procedures or equipment.
Potential Impacts
- On Citizens (Enrollees): Could reduce delays in accessing care, leading to timelier treatments and fewer disruptions, especially for seniors in Medicare Advantage (about half of Medicare beneficiaries). May lower health disparities in rural or low-income groups through faster "real-time" approvals for common services.
- On Government Agencies: Increases administrative burden for HHS and CMS in setting standards, collecting/analyzing data, publishing reports, and rulemaking (e.g., for access to criteria). Requires coordination with MedPAC and GAO for oversight reports, potentially informing future Medicare policy.
- On Providers and Plans: Providers gain easier electronic submissions and access to criteria, reducing paperwork; plans face compliance costs for systems and reporting but may see efficiencies from standardization. No direct impact on international relations, as this is domestic healthcare policy.
Main Stakeholders Affected
- Medicare Advantage Enrollees: Primarily seniors and disabled individuals relying on these private plans for Medicare benefits, who may experience improved access but could see plan premium or cost adjustments.
- Healthcare Providers and Suppliers: Doctors, hospitals, and equipment suppliers who submit requests; they benefit from transparency and faster processes but must adapt to electronic systems.
- Medicare Advantage Plans: Private insurers offering these plans (e.g., UnitedHealth, Humana); required to overhaul prior authorization operations, report data, and justify decisions.
- Federal Agencies: HHS, CMS (oversees implementation and data publication), and the Office of the National Coordinator (sets technical standards); also MedPAC and GAO for analysis.
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens regulatory oversight of private Medicare plans under the Social Security Act, potentially increasing enforcement actions for non-compliance (e.g., via notice-and-comment rulemaking). Introduces data privacy considerations in electronic transmissions, aligning with HIPAA but requiring new standards.
- Constitutional: No direct challenges; it operates within Congress's authority to regulate interstate commerce and social welfare programs like Medicare.
- Political: Bipartisan support (over 40 cosponsors from both parties) signals broad consensus on addressing prior authorization delays, a common complaint in healthcare. Could influence future reforms by providing data on AI use in denials, raising equity concerns without partisan framing.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (70)
Sen. Warner, Mark R. [D-VA], Sen. Hassan, Margaret Wood [D-NH], Sen. Fetterman, John [D-PA], Sen. Klobuchar, Amy [D-MN], Sen. Cassidy, Bill [R-LA], Sen. Capito, Shelley Moore [R-WV], Sen. Hickenlooper, John W. [D-CO], Sen. Lankford, James [R-OK], Sen. Merkley, Jeff [D-OR], Sen. Blackburn, Marsha [R-TN], Sen. Lummis, Cynthia M. [R-WY], Sen. Hyde-Smith, Cindy [R-MS], Sen. Kaine, Tim [D-VA], Sen. Shaheen, Jeanne [D-NH], Sen. Rounds, Mike [R-SD], Sen. Padilla, Alex [D-CA], Sen. Hagerty, Bill [R-TN], Sen. Kim, Andy [D-NJ], Sen. Boozman, John [R-AR], Sen. Durbin, Richard J. [D-IL], Sen. Cornyn, John [R-TX], Sen. Murray, Patty [D-WA], Sen. Moran, Jerry [R-KS], Sen. Gillibrand, Kirsten E. [D-NY], Sen. Cantwell, Maria [D-WA], Sen. Hirono, Mazie K. [D-HI], Sen. Tillis, Thomas [R-NC], Sen. Booker, Cory A. [D-NJ], Sen. Smith, Tina [D-MN], Sen. Welch, Peter [D-VT], Sen. Whitehouse, Sheldon [D-RI], Sen. Budd, Ted [R-NC], Sen. Cortez Masto, Catherine [D-NV], Sen. Sheehy, Tim [R-MT], Sen. Baldwin, Tammy [D-WI], Sen. Ricketts, Pete [R-NE], Sen. Blumenthal, Richard [D-CT], Sen. Warren, Elizabeth [D-MA], Sen. Duckworth, Tammy [D-IL], Sen. Hoeven, John [R-ND], Sen. Scott, Rick [R-FL], Sen. Kelly, Mark [D-AZ], Sen. Rosen, Jacky [D-NV], Sen. Heinrich, Martin [D-NM], Sen. Fischer, Deb [R-NE], Sen. Coons, Christopher A. [D-DE], Sen. Hawley, Josh [R-MO], Sen. Collins, Susan M. [R-ME], Sen. Warnock, Raphael G. [D-GA], Sen. Gallego, Ruben [D-AZ] and 20 more
Recent Actions
- 2025-05-20: Read twice and referred to the Committee on Finance.
- 2025-05-20: Introduced in Senate
Bill Versions
- Improving Seniors’ Timely Access to Care Act of 2025 — issued 2025-05-20 — PDF (17 pages)