Improving Seniors’ Timely Access to Care Act of 2025
The Improving Seniors’ Timely Access to Care Act of 2025 would expand and regulate how Medicare Advantage (MA) plans use prior authorization for items and services. Starting in 2027-2028, MA plans that require prior authorization would have to implement an electronic prior authorization program for transmitting requests and supporting documents, and meet new enrollee protection standards. Beginning in 2027, plans would also have to comply with transparency requirements, making detailed information about prior authorization practices available to the Secretary, enrollees, providers, and the public. The bill creates a framework for timeframes to respond to prior authorization requests and directs ongoing evaluation and reporting by GAO, MedPAC, CMS, and ONC to track implementation, effectiveness, and potential improvements, including the exploration of real-time, automated decisions for routinely approved items and services. Overall, the bill aims to reduce delays and unpredictability in access to care for MA enrollees by standardizing electronic prior authorization, increasing transparency, protecting enrollees, and encouraging advance use of real-time decision tools. It also gives the Secretary authority to set response timeframes and requires regular public reporting and oversight.
Key Points
- 1Electronic prior authorization program required for MA plans with any prior authorization beginning with plan years after January 1, 2028, plus enforce enrollee protection standards starting after January 1, 2027.
- 2Electronic prior authorization program defined as secure electronic transmission of requests and supporting documentation between providers/suppliers and MA plans; excludes faxes and nonstandard portals; must meet Secretary-approved technical standards.
- 3Transparency and data reporting requirements: MA plans must annually report to the Secretary a comprehensive set of metrics (items subject to prior authorization, approval/denial rates, appeal statistics, time to decision, use of decision-support technologies, grievances, and other information determined by the Secretary) and provide access to criteria and documentation to providers, suppliers, and enrollees upon request; information published on CMS public website at the plan level.
- 4Real-time decision and technology use: CMS/ONC must publish a plan to define “real-time decision,” explore its use for routinely approved items, and assess whether automation/AI could improve access, efficiency, and reduce disparities; MedPAC to report on use of prior authorization and recommend improvements.
- 5Enrollee protection standards: require transparent prior authorization programs, potential waivers/modifications based on provider performance and adherence to evidence-based guidelines, and annual reviews of items/services with prior authorization requirements.
- 6Timeframes for responses: Secretary can establish timeframes (e.g., 24 hours) for notifying enrollees and involved physicians of determinations in expedited, real-time, or other prior authorization requests, subject to existing law.
- 7Reports to Congress: GAO must evaluate implementation by 2032; HHS/CMS must produce regular reports detailing submitted data and process improvements; a separate CMS/ONC report by 2028 on real-time decision processes and related analyses.