House committees pass bill to improve prior authorization in Medicare Advantage

The House Ways and Means and Energy and Commerce Committees have voted on a bi-partisan basis to pass the Improving Seniors Timely Access to Care Act (H.R.3514) which would strengthen rules and procedures governing how Medicare Advantage (MA) plans can use prior authorization to restrict patient benefits including for OT services. The bill was introduced by Reps Mike Kelly (R-PA) and Susan DelBene (D-WA) and now awaits further action in the full House and Senate.

The bill would require standard prior authorization requests to be completed in seven days and urgent requests in 72 hours. It would also streamline and simplify pre-approvals by transitioning to an electronic prior authorization process. In addition, it would require MA plans to publicly disclose prior authorization statistics including the number of requests, denials and approvals as well as the time to resolution while taking other steps to increase the amount of information regarding prior authorization available to the public.

This legislation is especially important as 54 percent of Medicare beneficiaries are enrolled in an MA plan, and in 2024, MA insurers received 53 million prior authorization requests or an average of 1.7 requests per enrollee. Therapy providers have been faced with burdensome delays and denials of care from MA plans with significant issues related to United HealthCare plans emerging in 2024, although a coalition of therapy provider groups worked with the Centers for Medicare and Medicaid Services (CMS) and UHC to address some of the most egregious issues.

AOTA and partners have developed a policy framework to improve prior authorization processes for therapy providers, and enactment of H.R.3514 would help to set conditions whereby prior authorization requests can be minimized and processed in a timely and less burdensome fashion. This would enable patients to receive essential therapy services when needed.