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  • Prior Authorization Reform Effort Gets Boost from CMS

    Centers for Medicare & Medicaid Services’ proposed rule smooths way for passage of the Improving Seniors’ Timely Access to Care Act

    Washington, D.C.— The Centers for Medicare & Medicaid Services (CMS) released a proposed rule that closely aligns with the Improving Seniors’ Timely Access to Care Act (S. 3018/H.R. 3173), a bill the American Academy of Ophthalmology helped craft. If adopted, the rule would require Medicare Advantage and states to streamline prior authorization processes and improve the electronic exchange of health data by 2026. The timing of the proposed rule is helpful to the bill’s passage, as Congress could weigh in on the issue by the end of the year.

    Although the House-passed bill has strong bipartisan support, it has stalled in the Senate over the potential cost estimate. The Congressional Budget Office estimated the bill would cost $16 billion over 10 years due to the additional care that would be provided. Several groups, including the Academy, the bill’s sponsors and other stakeholders, strongly disagree with how the budget office calculated the cost. The proposed rule released last week should reduce the cost of the bill since it would implement some of the bill’s provisions.

    The proposal shares many elements of the legislation for improving prior authorization. Most notably, the rule and the bill both:

    • Seek to reduce care delays and improve patient outcomes
    • Aim to advance interoperability and improve prior authorization processes by requiring Medicare Advantage plans to adopt electronic prior authorization
    • Ensure Medicare Advantage plans respond to prior authorization requests within specific timeframes
    • Require public reporting on the use of prior authorization with specific and detailed transparency on Medicare Advantage prior authorization
    • Support efforts to waive or modify prior authorization requirements based on provider performance
    • Acknowledge that health plans’ proprietary interfaces and web portals through which providers submit their requests remain inefficient and burdensome

    “The rule advances several of our goals including speeding approvals, increased prior authorization transparency and is a win for physicians and America’s seniors,” said George A. Williams, MD, the Academy’s senior secretary for advocacy. “Our patients can’t wait any longer for relief.”

    We will continue to press for the bill’s passage before this Congress ends its session on Dec. 31. Even if this Congress doesn’t pass the bill, the proposed rule could lead to some of the same reforms.

    The Academy is a founding member of the Regulatory Relief Coalition , a group of national physician specialty organizations advocating for regulatory burden reduction in Medicare. The Regulatory Relief Coalition is a lead architect and organizational advocate of the Improving Seniors’ Timely Access to Care Act. The bipartisan bill was supported by more than 375 combined House and Senate co-sponsors and over 500 endorsing organizations representing patients, health care providers, medical technology and biopharmaceutical industry, health plans, and others.

    About the American Academy of Ophthalmology 

    The American Academy of Ophthalmology is the world’s largest association of eye physicians and surgeons. A global community of 32,000 medical doctors, we protect sight and empower lives by setting the standards for ophthalmic education and advocating for our patients and the public. We innovate to advance our profession and to ensure the delivery of the highest-quality eye care. Our EyeSmart® program provides the public with the most trusted information about eye health. For more information, visit