H.R. 9396: Prior Authorization Accountability Act

This bill would require health plans and health insurance companies to publicly disclose more information about prior authorization decisions, which are the approvals insurers often require before covering certain medical services, tests, or treatments.

What plans would have to publish

For health plans and insurers that use prior authorization, starting with plan years on or after January 1, 2027, the bill would require them to post and submit information such as:

• A list of all items and services that required prior authorization during the year.
• How many requests were approved or denied at the initial decision stage, both overall and by specific item or service.
• How many denied requests were later appealed.
• How many appeals were successful, including success at different levels of appeal, up to judicial review.
• The average and median time it took to get a decision, measured in hours.
• How many approvals and denials were made using automated tools such as decision-support software, artificial intelligence, or machine-learning systems.
• A description of any such technology used in prior authorization decisions.

Who would be covered

The requirements would apply to:

• Group health plans and health insurance issuers offering group coverage.
• Health insurance issuers offering individual coverage.
• Plans and issuers offering coverage through Affordable Care Act exchanges, with additional public reporting requirements for exchange-based coverage.
• Employer-sponsored plans subject to ERISA and plans covered under the Internal Revenue Code.

Where the information would be posted

The bill says the information must be submitted to the federal government and made available on a public website of the plan or insurer. The Secretary of Health and Human Services would set the timing and format. The Secretary could also require the data to be shown in aggregate form, such as across all plans offered by the same company or sponsor.

Effect on ACA exchange comparisons

For qualified health plans sold through Affordable Care Act exchanges, starting with plan years on or after January 1, 2029, the exchange’s comparison website would need to include the most recent prior-authorization transparency information submitted by the insurer. This is meant to make plan comparisons more informative for consumers.

Overall effect

In practical terms, the bill would not ban prior authorization. Instead, it would require plans and insurers to be much more transparent about how often they approve or deny requests, how long decisions take, how appeals turn out, and whether automated technology is being used in the process.

Relevant Companies

• UNH — UnitedHealth Group, which operates a large health insurance business and uses prior authorization in many plans.
• HUM — Humana, a major insurer with coverage lines likely subject to these reporting requirements.
• CVS — CVS Health, through Aetna, offers health insurance plans that would need to comply with the disclosure rules.
• CI — Cigna, a large health insurer that would likely need to publish prior authorization data.
• ELV — Elevance Health, whose health plans would likely be covered by the transparency requirements.
• MRK — Merck, and other drug manufacturers indirectly affected if greater transparency changes insurer approval practices for certain treatments.