Reps. Bera, DelBene Sound Alarm Over HHS Plan Adding Red Tape to Medicare

Washington, D.C. — Representatives Ami Bera, M.D. (CA-06) and Suzan DelBene (WA-01) led a group of 15 House Democrats in a letter urging the U.S. Department of Health and Human Services (HHS) to reconsider a proposal that would add new prior authorization requirements to traditional Medicare, a decision that could delay care and worsen health outcomes for millions of seniors.

In June, HHS announced a plan to begin adding prior authorization requirements to Medicare Fee-for-Service by contracting with private companies, including some of the Medicare Advantage plans that use the practice to delay and deny care. The proposal would be tested in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. It would be applied to several services. Days prior to this announcement, the HHS and CMS touted a non-binding commitment from insurance plans to work to reduce prior authorization in Medicare Advantage.

“The use of prior authorization in Medicare Advantage shows us that, in practice, [this proposal] will likely limit beneficiaries’ access to care, increase burden on our already overburdened health care work force, and create perverse incentives to put profit over patients.” the lawmakers wrote. “The Trump Administration publicly recognized the harm of prior authorization…And yet, not a week after these statements, CMS put forward a new proposal to increase the utilization of prior authorization in a type of health coverage that had seldom used the tactic before, replacing doctor’s medical knowledge with an algorithm designed to maximize care denial in order to increase profits.”

In recent years, HHS revealed that Medicare Advantage plans ultimately approved 75% of requests that were originally denied. More recently, HHS released a report finding that MA plans incorrectly denied beneficiaries access to services even though they met Medicare coverage rules. The bill focuses on holding Medicare Advantage plans accountable and transparent to the American public.

The letter asks for answers to the following questions about how it’ll be implemented by September 1, 2025:

• What criteria were used to select the six states for this model?
• What services will be subject to prior authorization in each state? Will the model operate on a statewide basis for all services and in all states or will there be variation among states (and if so please describe)?
• How will entities performing prior authorization be selected? What qualifications will be required to ensure that reviewers have appropriate expertise?
• How will patients and providers be educated about the new prior authorization requirements and appeals rights?
• What review of the contracted entities’ algorithms will occur to ensure that inappropriate denials of medically necessary care do not occur?
• What performance metrics will be required for entities performing prior authorization? How quickly must entities issue decisions? Will there be sanctions for participants that to not render decisions timely? Will prior authorization denials count as benefit denials that allow patients to access appeal rights?
• Has CMS studied how prior authorization in Traditional Medicare may increase rates of physician burden and burnout?
• CMS has indicated that model participants will be compensated based on a share of “averted expenditures.” This approach appears to reward participants based on the volume or cost of care they prevent from being delivered or paid, yet past experience from Medicare Advantage and other markets shows that this incentive has often led to inappropriate denials.
• What protections or thresholds will CMS impose to ensure that denials are evidence-based, not volume-driven?

Additional signers of the letter include Representatives Eleanor Holmes Norton (DC-At Large), Linda Sánchez (CA-38), Brad Schneider (IL-10), Danny Davis (IL-07), Don Beyer (VA-08), Nikki Budzinski (IL-13), Jimmy Panetta (CA-19), Jonathan Jackson (IL-01), Marilyn Strickland (WA-10), Terri Sewell (AL-07), Marc Veasey (TX-33), Judy Chu (CA-28), Emily Randall (WA-06), Raja Krishnamoorthi (IL-08), and Mary Kaptur (OH-09).

The full letter can be found here.

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