Res No. 1026

Resolution calling on the United States Congress to reintroduce and pass, and the President to sign, S.4532/H.R.8702, the Improving Seniors’ Timely Access to Care Act, which will improve the speed at which seniors with Medicare Advantage plans may access approved care

By Council Members Schulman and Louis

                     Whereas, A prior authorization, according to the Center for Medicare Advocacy (CMA), is a requirement that a health care provider obtain approval from Medicare to provide a given service; and

                     Whereas, According to KFF, formerly known as the Kaiser Family Foundation, prior authorization requirements are used to ensure health care services are medically necessary and, along with other tools like provider networks, to lower costs; and

                     Whereas, According to KFF, nearly all enrollees in Medicare Advantage Plans, about 99%, are required to obtain prior authorization for some services, usually higher cost services like inpatient hospital stays, skilled nursing facility stays, and chemotherapy; and

Whereas, According to the Medical Society of the State of New York, from 2019 to 2023, physicians have seen a dramatic increase in the use of prior authorization protocols by insurance companies; and

                     Whereas, In New York City (NYC), the NYC Medicare Advantage Plus Plan is offered through an alliance between Empire BlueCross BlueShield Retiree Solutions and EmblemHealth; and

                     Whereas, This plan requires prior authorization for services including, but not limited to: (1) inpatient admissions including elective inpatient admissions, rehabilitation facility admissions, skilled nursing facility admissions, and long-term acute care; (2) select outpatient services like orthotics, elective inpatient surgery, physical therapy, oncology, genetic testing, and more; (3) durable medical equipment and prosthetics like ventilators, insulin and infusion pumps, automated external defibrillators, and more; (4) radiology services like CT scans, echocardiograms, MRI scans, and more; (5) behavioral health services; and (6) transplants including, but not limited to, inpatient procedures such as heart, kidney, liver, or lung transplants and outpatient procedures like donor leukocyte infusions; and

                     Whereas, While organizations like KFF have argued that prior authorization may allow Medicare Advantage insurers to offer extra benefits, reduce cost sharing, and maintain strong financial performance, other organizations like CMA argue that prior authorizations do not improve care, they only reduce costs for insurers; and

                     Whereas, According to CMA, the Social Security Act did not originally permit any form of prior authorization and while this has changed slightly, prior authorization requirements in traditional Medicare plans remain rare, usually only for limited items of Durable Medical Equipment and some physicians’ services; and

                     Whereas, According to CMA, Medicare Advantage insurers made nearly 50 million prior authorization determinations in the United States in 2023, a rate of nearly 2 determinations per Medicare Advantage enrollee; and

                     Whereas, According to CMA, 3.2 million prior authorization requests were fully or partially denied, about 6.4% of all requests; and

                     Whereas, According to CMA, of those denials, 11.7% were appealed, and of those appeals, 81.7% were fully or partially successful; and

                     Whereas, The Centers for Medicare and Medicaid Services has finalized its proposals relating to prior authorization timeframes for certain payers, with expedited requests requiring a response in 72 hours, and standard requests requiring a response in 7 calendar days with the possibility of an extension to 14 calendar days; and

Whereas, The Improving Seniors’ Timely Access to Care Act was introduced in the United States House of Representatives as H.R.8702 by Representative Mike Kelly on June 12, 2024, and in the United States Senate as S.4532 by Senator Roger Marshall on June 13, 2024; and

                     Whereas, This legislation would amend Title XVIII of the Social Security Act (Title XVIII) to establish requirements with respect to the use of prior authorization under Medicare Advantage plans; and

                     Whereas, These requirements include the establishment of the electronic prior authorization program, which would streamline the prior authorization request process, and the establishment of enrollee protection standards, which will increase transparency in the prior authorization request decision making process; and

                     Whereas, This legislation would also allow the Secretary of Health and Human Services to establish timeframes for insurers to notify the enrollee, and the physician when appropriate, of their decision regarding the prior authorization request; and

                     Whereas, Given the amount of denied prior authorization requests which are overturned upon appeal and the potentially long wait times for patients who require life-saving medical treatment in a time appropriate manner, these adjustments to Title XVIII are crucial; and

Whereas, An original version of this legislation was introduced in Congress as S.3018/H.R.3173 in the 2021-22 legislative session; and

Whereas, H.R.3173 passed in the House of Representatives, highlighting previous movement of the Improving Seniors’ Timely Access to Care Act; now, therefore, be it

                     Resolved, that the Council of the City of New York calls on the United States Congress to reintroduce and pass, and the President to sign, S.4532/H.R.8702, the Improving Seniors’ Timely Access to Care Act, which will improve the speed at which seniors with Medicare Advantage plans may access approved care.

LS 18836

3/13/2025

JN