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Mary Beth Donahue (Photo: Better Medicare Alliance)

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Medicare Advantage Group Throws Weight Behind House Care Access Bill

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What You Need to Know

  • The Improving Seniors' Timely Access to Care Act would create an electronic preauthorization process and pave the way for instant approvals of certain procedures.
  • The Better Medicare Alliance, a coalition with many insurer members, has now endorsed the bill, which could improve its chances of passage.
  • The bill has strong, bipartisan support in both the House and the Senate.

The Better Medicare Alliance — a group with strong ties to Medicare Advantage plan issuers — has decided to support a bill intended to streamline preauthorization of care in the Medicare Advantage program.

BMA’s decision to endorse the Improving Seniors’ Timely Access to Care Act could greatly increase the odds that it will become law. The House version is H.R. 3173, and the Senate version is S. 3018.

If the bill becomes law, and if it works as supporters predict, it could slash the number of older clients who come in with complaints about getting health plans to approve the care recommended by their physicians.

What It Means

Traditionally, many clients with the means to pay monthly premiums for Medicare supplement insurance have combined “original Medicare” coverage with Medicare supplement insurance, because of concerns about Medicare Advantage plans’ use of provider networks and active management of care.

If a Medicare Advantage preauthorization bill becomes law and leads to a significant improvement in how smoothly enrollees get access to care, it could make Medicare Advantage plans more appealing for some clients.

Monthly premium costs for Medicare Advantage plan enrollees are often lower than total costs for clients using original Medicare with Medicare supplement insurance, and that means affected clients may be able to reduce the amount of income allocated for health insurance premiums.

Preauthorization

Health plans use preauthorization procedures to review health care providers’ recommendations for certain types of care, such as CAT scans, expensive medications and surgery.

Health plans have argued that well-run preauthorization programs and related programs are critical to protecting patients against drugs and procedures that might cost too much, might be unnecessary, or that might even hurt them.

Provider groups have acknowledged that some kinds of review might be necessary, but they have argued that, in practice, review programs often appear to be rigid, arbitrary and difficult for physicians to work with.

The Bills

H.R. 3173, the House version of the bill, was introduced in May 2021 by Rep. Suzan DelBene, D-Wash.

The bill is under the jurisdiction of the House Ways and Means Committee and the House Energy and Commerce Committee, which have not yet held hearings on the bill.

H.R. 3173 has 173 Democratic co-sponsors and 123 Republican co-sponsors.

Sen. Roger Marshall, R-Kansas, introduced the Senate companion bill, S. 3018, in October 2021.

S. 3018 has 16 Democratic co-sponsors and 14 Republican co-sponsors.

The Bill Text

Both bills would establish an electronic prior authorization process, and require regulators at the U.S. Department of Health and Human Services to establish a process for instant decisions for items and services that are typically approved.

Medicare Advantage plans would have to send prior authorization program data to the Centers for Medicare and Medicaid Services, the HHS arm that oversees Medicare plans.

The bills would encourage plans to work with physicians to develop preauthorization programs based on established medical guidelines.

The Supporters

When DelBene introduced her bill, she had support from a long list of patient and health care provider groups, including the American Medical Association and the Federation of American Hospitals.

Insurer groups said they supported the idea of improving preauthorization programs but held off on supporting the bill.

The U.S. Department of Health and Human Services Office of Inspector General may have changed the climate for the bill in April, by releasing a report finding a 13% error rate in Medicare Advantage plan preauthorization program denials.

America’s Health Insurance Plans noted that Medicare Advantage plans approve many procedures without use of preauthorization reviews, and approve 95% of procedure requests that go through preauthorization reviews.

But news coverage of the report drew media and patient group attention to the topic.

Mary Beth Donahue, president and CEO of the Better Medicare Alliance, has criticized some of the press coverage of the inspector general’s office report on preauthorization denials, but emphasized that the group believes in the importance of simplifying the preauthorization process.

The preauthorization bill “is a commonsense solution that builds on the work the Medicare Advantage community has been doing to streamline prior authorization for seniors,” Donahue said, in a comment included in the alliance announcement about the decision to support the bill.

The alliance looks forward to working with CMS, health care providers and other stakeholders to move to electronic prior authorization protocols, Donahue said.

Pictured: Mary Beth Donahue (Photo: Better Medicare Alliance)