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S. 1816: Improving Seniors’ Timely Access to Care Act of 2025

This bill, titled the Improving Seniors’ Timely Access to Care Act of 2025, aims to establish new requirements regarding the use of prior authorization in Medicare Advantage plans. Prior authorization is a process designed to ensure that certain health care services and items are approved before they are provided, but it can also lead to delays in receiving care.

Key Provisions

Establishment of Electronic Prior Authorization: Starting on January 1, 2028, Medicare Advantage plans that require prior authorization must implement an electronic system that allows for secure digital submission of requests for authorization from health care providers, alongside any necessary supporting documentation.
Transparency Requirements: By January 1, 2027, these plans must adhere to new transparency measures, which involve reporting various statistics related to prior authorization requests. They will need to disclose:
- The items and services subject to prior authorization
- The percentage of requests approved and denied
- The number of appeals made and their outcomes
- The average time taken for decisions on requests
- Any technology used in decision-making for prior authorization
- Grievances related to prior authorization requirements
Enrollee Protection Standards: The bill sets guidelines to ensure that prior authorization processes are transparent and developed in consultation with patients and healthcare providers. This includes provisions for potentially waiving or modifying requirements based on provider performance and conducting annual reviews of the items and services subject to prior authorization.
Timely Responses to Requests: There will be legal authority for the Secretary of Health and Human Services to impose time limits on how quickly Medicare Advantage plans must respond to prior authorization requests, with a minimum timeframe of 24 hours set for expedited requests.

Implementation and Oversight

The Centers for Medicare & Medicaid Services (CMS) will be responsible for establishing the necessary regulations and will publish information about prior authorization on a public website, broken down by individual plans for public access.
Reports will be required every few years that evaluate and analyze how these prior authorization requirements are being implemented, including insights into the effectiveness of electronic systems and compliance with new regulations.

Applicable Items and Services

For the purposes of this bill, any item or service covered under a Medicare Advantage plan, except for covered Part D drugs, falls under the category of applicable items and services subject to these new prior authorization requirements.