[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4968 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 4968
To amend title XVIII of the Social Security Act to exempt qualifying
physicians from prior authorization requirements under Medicare
Advantage plans, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 27, 2023
Mr. Burgess (for himself and Mr. Vicente Gonzalez of Texas) introduced
the following bill; which was referred to the Committee on Ways and
Means, and in addition to the Committee on Energy and Commerce, for a
period to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to exempt qualifying
physicians from prior authorization requirements under Medicare
Advantage plans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Getting Over Lengthy Delays in Care
As Required by Doctors Act of 2023'' or the ``GOLD CARD Act of 2023''.
SEC. 2. EXEMPTION FOR QUALIFYING PHYSICIANS FROM PRIOR AUTHORIZATION
REQUIREMENTS UNDER MA PLANS.
(a) In General.--Section 1852 of the Social Security Act (42 U.S.C.
1395w-22) is amended by adding at the end the following new subsection:
``(o) Exemption for Qualifying Physicians From Prior Authorization
Requirements.--
``(1) In general.--
``(A) Exemption.--
``(i) In general.--In the case of an MA
organization which utilizes a prior
authorization process (as defined in
subparagraph (B)) with respect to a plan year
(beginning with the second plan year beginning
after the date of the enactment of this
subsection), subject to the succeeding
provisions of this subsection, a physician
shall be exempt from the prior authorization
requirements under such process for the period
of such plan year with respect to a specific
item, service, or group of similar services, if
during the preceding plan year at least 90
percent of prior authorization requests
submitted to such organization by such
physician for such item, service, or group were
approved by such organization (including any
approval granted after an appeal). Such
exemption shall continue to apply with respect
to such physician furnishing such item,
service, or group of similar services in
subsequent plan years until the earlier of--
``(I) the date on which such
exemption is revoked under paragraph
(5); or
``(II) the date on which such
physician opts out of such exemption
under paragraph (3)(C).
``(ii) Special rules.--For purposes of
determining whether a physician qualifies for
an exemption under clause (i) for a plan year
for an item, service, or group of services, in
calculating whether at least 90 percent of
prior authorization requests submitted by such
physician for such item, services, or group
during the preceding plan year were approved,
an MA organization shall--
``(I) subject to subclause (II),
treat any such claim that was initially
denied, subsequently appealed, and that
remains pending appeal at the time of
such calculation as having been
approved if more than 30 days have
elapsed since the date such appeal was
filed; and
``(II) in the case that, during
such plan year, such organization
changed any terms of coverage for such
item, service, or group of services,
not take into account any claims for
such item, service, or group of
services that were submitted during the
90-day period beginning on the date of
such change.
``(B) Prior authorization process.--For purposes of
this subsection, the term `prior authorization process'
means, with respect to coverage and payment for items
and services (other than a covered part D drug) under
an MA plan offered by an MA organization for a plan
year, a process under which such organization (or a
contractor of such organization) determines the medical
necessity or medical appropriateness of such items and
services prior to the furnishing of such items and
services or that otherwise requires an individual
enrolled under such plan, or a provider of services or
supplier scheduled to furnish items and services to
such individual, to notify such plan (or such
contractor) prior to such individual receiving such
items and services.
``(2) Frequency of determination of eligibility for
exemption.--An MA organization may not evaluate a physician for
the exemption described in paragraph (1) more than once during
any plan year.
``(3) Notification requirements.--
``(A) Qualification.--An MA organization shall, not
later than 30 days before the first day of each plan
year, notify each physician who qualifies for the
exemption described in paragraph (1) of such
qualification and the items, services, or group of
similar services with respect to which such exemption
applies for such physician. Nothing in this
subparagraph shall preclude an MA organization from
notifying a physician of such exemption at additional
times throughout a plan year.
``(B) Requests under exemption.--In the case of a
physician described in subparagraph (A) who submits a
prior authorization request to an MA organization for
an item or service with respect to which an exemption
applies under this subsection, such organization shall
notify such physician of such exemption as soon as
possible (but in no case later than 24 hours after
receiving such request).
``(C) Opt out.--Any physician eligible for an
exemption under paragraph (1) may voluntarily waive
such exemption by providing written notice to the
applicable MA organization.
``(4) Requirement for coverage and payment.--In the case of
a physician who qualifies for the exemption described in
paragraph (1) with respect to an item, service, or group of
similar services, an MA organization may not deny or reduce
coverage and payment for such an item, service, or group based
on medical necessity or appropriateness of care.
``(5) Protections pertaining to revocation of gold card.--
``(A) In general.--An MA organization may revoke an
exemption described in paragraph (1) granted with
respect to a physician for an item, service, or group
of similar services for a plan year only if--
``(i) the MA organization--
``(I) determines that--
``(aa) less than 90 percent
of claims submitted by such
physician for such item,
service, or group during the
90-day period ending on the
date of such revocation would
have been approved under the
prior authorization process
employed by such plan had such
process applied with respect to
such claims; or
``(bb) in the case that
fewer than 10 claims were
submitted by such physician for
such item, service, or group
during the 90-day period ending
on the date of such revocation,
less than 90 percent of the
last 10 claims submitted by
such physician for such item,
service, or group as of the
date of such revocation would
have been so approved;
``(II) furnishes such physician
with a notice of such revocation
containing the claim information
(including identification of specific
items and services and the individual
to whom such items and services were
furnished) on which the determination
under subclause (I) was made; and
``(III) includes in such notice a
plain-language description of how such
physician may appeal such determination
in accordance with the rules
promulgated under subparagraph (B); and
``(ii) the individual conducting the
determination under clause (ii)(I)--
``(I) is a physician;
``(II) possesses a current and
nonrestricted license to practice
medicine in the State in which the
items, services, or group of services
to which such exemption applies were
furnished;
``(III) is actively engaged in the
practice of medicine in the same or
similar specialty as a physician that
would typically furnish such item,
service, or group of services; and
``(IV) is knowledgeable about the
furnishing of, and has experience
furnishing, such item, service, or
group of services.
``(B) Appeal of exemption.--The Secretary shall,
through notice and comment rulemaking, establish a
process under which a physician may appeal a revocation
under subparagraph (A). Such process shall ensure that
any such appeal is resolved within 30 days of such
appeal being submitted under such process.
``(C) Treatment of unresolved claims.--The
provisions of paragraph (1)(A)(ii) shall apply with
respect to the treatment of claims for a determination
made under subparagraph (A) in the same manner as such
provisions apply with respect to the treatment of
claims for a determination made under paragraph
(1)(A).''.
(b) Rulemaking.--The Secretary of Health and Human Services shall,
through rulemaking, specify requirements with respect to the use of
prior authorization by Medicare Advantage plans for items and services
described in subsection (o)(1) of section 1852 of the Social Security
Act (42 U.S.C. 1395w-22), as added by subsection (a), to ensure
continuity of care for individuals transitioning to, or between,
coverage under such plans in order to minimize any disruption to
ongoing treatment attributable to prior authorization requirements
under such plans.
(c) Report.--Not later than 2 years after the date of the enactment
of this Act, the Secretary of Health and Human Services shall submit to
Congress a report on the potential impacts of the amendment made by
this section on communities at high risk for health disparities.
SEC. 3. OPPORTUNITY FOR PROVIDERS TO PRESENT CASES FOR COVERAGE AND
PAYMENT DURING THE PRIOR AUTHORIZATION PROCESS UNDER MA
PLANS.
Section 1852 of the Social Security Act (42 U.S.C. 1395w-22), as
amended by section 2, is further amended by adding at the end the
following new subsection:
``(p) Opportunity for Providers To Present Cases for Coverage and
Payment During the Prior Authorization Process.--
``(1) In general.--For plan years beginning with the second
plan year beginning after the date of the enactment of this
subsection, any prior authorization process (as defined in
subsection (o)(1)(B)) with respect to the coverage and payment
for items and services (other than a covered part D drug) under
an MA plan offered by an MA organization shall provide, prior
to any coverage or payment determination with respect to an
item or service subject to such process, for an opportunity for
a provider of services or supplier seeking prior authorization
to furnish such item or service to discuss with a qualifying
physician (as defined in paragraph (2))--
``(A) the treatment plan for the individual who
would be furnished such item or service; and
``(B) the clinical basis on which the organization
will determine coverage or payment for such item or
service.
``(2) Qualifying physician defined.--For purposes of
paragraph (1), the term `qualifying physician' means, with
respect to an item or service subject to a process described in
such paragraph that a provider of services or supplier is
seeking to furnish to an individual, a physician that--
``(A) possesses a current and nonrestricted license
to practice medicine in the State in which such item or
service is to be furnished;
``(B) is actively engaged in the practice of
medicine in the same or similar specialty as a provider
of services or supplier that would typically furnish
such item or service; and
``(C) is knowledgeable about the furnishing of, and
has experience furnishing, such item or service.''.
<all>