To amend title XVIII of the Social Security Act to establish certain requirements with respect to rates of reversed prior authorization coverage determinations under Medicare Advantage plans.
Summary
H.R. 6109 aims to amend Title XVIII of the Social Security Act, focusing on Medicare Advantage plans. It seeks to establish requirements regarding the rates at which prior authorization coverage denials are reversed. The bill stipulates that if a Medicare Advantage plan exceeds a certain threshold for reversed prior authorization denials, the Secretary of Health and Human Services shall terminate the plan's contract.
Expected Effects
The bill's enactment would likely lead to increased scrutiny of Medicare Advantage plans' prior authorization processes. Plans exceeding the allowable reversal rate could face contract termination, potentially impacting beneficiaries' access to those plans. It could also incentivize plans to improve their initial coverage determination accuracy.
Potential Benefits
- Improved Healthcare Access: By limiting excessive prior authorization denials, beneficiaries may experience fewer delays in receiving necessary medical care.
- Increased Transparency: The bill promotes greater transparency in coverage determination processes within Medicare Advantage plans.
- Enhanced Accountability: Medicare Advantage plans would be held more accountable for their prior authorization decisions.
- Reduced Administrative Burden: Streamlining the prior authorization process could reduce administrative burdens for both patients and healthcare providers.
- Potentially Lower Healthcare Costs: By reducing unnecessary denials and appeals, the bill could contribute to lower healthcare costs in the long run.
Most Benefited Areas:
Potential Disadvantages
- Potential for Increased Premiums: Medicare Advantage plans may increase premiums to offset the costs of complying with the new requirements.
- Possible Reduction in Plan Choices: Some plans may choose to exit the market rather than comply, reducing choices for beneficiaries.
- Risk of Gaming the System: Plans might find ways to circumvent the requirements without genuinely improving coverage determinations.
- Implementation Challenges: The Secretary of Health and Human Services may face challenges in accurately determining and enforcing the allowable reversal rate.
- Unintended Consequences: The bill could lead to unintended consequences, such as plans becoming overly cautious in approving prior authorizations.
Constitutional Alignment
The bill aligns with the General Welfare Clause of the Constitution, as it aims to improve healthcare access and accountability within Medicare Advantage plans. Congress has the power to legislate on matters related to Social Security under its enumerated powers. The bill does not appear to infringe upon any specific constitutional rights or limitations.
Impact Assessment: Things You Care About ⓘ
This action has been evaluated across 19 key areas that matter to you. Scores range from 1 (highly disadvantageous) to 5 (highly beneficial).