Improving Seniors’ Timely Access to Care Act of 2025
The Improving Seniors’ Timely Access to Care Act of 2025 would overhaul how Medicare Advantage (MA) plans handle prior authorization. It requires MA plans that impose any prior authorization to implement an electronic prior authorization system and to meet new transparency and enrollee protections. Starting in 2027, MA plans must begin complying with transparency requirements; starting in 2028, they must implement a secure, standardized electronic prior authorization program. The bill also creates enforceable timelines for responses, directs ongoing reporting and oversight (including by MedPAC and GAO), and sets up processes to study and promote real-time/automated decision-making for routinely approved items and services. The overarching goal is to reduce delays in care and improve access for MA enrollees (seniors and certain disabled individuals) by increasing transparency, standardizing processes, and speeding determinations. Key elements include publication of plan-level prior authorization data, access to criteria used for determinations, annual reporting on approvals/denials and appeals, consideration of use of technology in determinations, and an emphasis on reducing health disparities (including in rural and low-income communities) through potential real-time decisions. The bill also authorizes the Secretary to set timeframes for prior authorization responses, including expedited determinations, and requires periodic government reviews of the program’s effectiveness and impact.
Key Points
- 1Electronic prior authorization program required for MA plans with any prior authorization, beginning plan years after January 1, 2028; plans must also meet enrollee protection standards beginning with plan years after January 1, 2027.
- 2Transparency requirements: MA plans must annually report to the Secretary detailed data on prior authorization, including items/services subject to prior authorization, approval/denial rates, appeals outcomes, use of decision-support/AI/ML, average/median review times, and grievances; plans must also disclose criteria used for determinations to providers, suppliers, and enrollees (upon request).
- 3Enrollee protection standards: transparent programs developed with input from enrollees and providers, flexibility to waive or modify certain prior authorizations based on provider performance, and annual reviews of prior authorization items/services with input from enrollees and contracted providers/suppliers.
- 4Real-time decisions and timeframes: the Secretary may establish timeframes (e.g., 24 hours) for response to certain requests, including expedited determinations and real-time decisions for routinely approved items; the bill also directs development of processes for real-time decisions through a subsequent CMS/ONC report.
- 5Oversight and reporting: MedPAC must report to Congress within three years on implementation and needs; the Secretary must submit biennial reports detailing the information reported under the transparency provisions; CMS and ONC must publish a real-time decision framework and analysis by January 1, 2028, with ongoing updates; a GAO evaluation is required by January 1, 2032.
- 6Scope: the provisions apply to MA plan benefits that are not Part D drugs, focusing on items/services for which MA plans provide benefits.