Aug. 11, 2023: National Advocacy Update

On July 26, the AMA applauded the House Ways and Means Committee for advancing legislation that included provisions that closely mirror the Improving Seniors’ Timely Access to Care Act. Introduced by Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, MD (D-CA) and Larry Bucshon, MD (R-IN) in the 117th Congress, this legislation, which ultimately passed the House of Representatives in 2022, garnered 52 Senate and 326 House cosponsors along with the support of over 500 health care organizations. The Improving Seniors’ Timely Access to Care Act was included as Section 301 in H.R. 4822, the Health Care Price Transparency Act of 2023, which passed the Ways and Means Committee on a partisan line vote of 25-16. The AMA did not take a position on H.R. 4822.   

The AMA remains a long-standing champion of the Improving Seniors’ Timely Access to Care Act, which seeks to simplify, streamline and standardize the use of prior authorization within Medicare Advantage (MA). The bill mandates MA plans implement electronic prior authorization programs that adhere to newly developed standards by the federal government, as well as deems faxes, e-forms and proprietary websites that fail to meet these new technical requirements as noncompliant forms of utilization management. The legislation also requires health plans to provide real-time prior authorization decisions for routinely approved services. Real-time prior authorization decisions can only be avoided under extenuating circumstances and, even then, manual reviews for emergent services and standard care must be completed within 24 hours and 72 hours, respectively. The legislation also requires prior authorization decisions for all other Part C services to be reached within 24 hours for emergent services and no later than 7 days for standard care. 

The advancement of legislation comes on the heels of June 21 House and Senate letters (PDF) to CMS urging expeditious completion of a pending prior authorization regulation from CMS. The letter, which was led by Senators Sherrod Brown (D-OH), Roger Marshall, MD (R-KS), Kyrsten Sinema (I-AZ) and John Thune (R-SD), as well as Representatives DelBene, Kelly, Bera, MD, and Bucshon, MD, garnered 61 bipartisan Senate and 233 bipartisan House signatures. The AMA worked diligently to urge federal elected officials to cosign these letters. In addition to pressing the executive branch to finalize recently proposed regulations that would implement many of the same reforms, the letter requests CMS to further strengthen the pending proposal by: 

1. Establishing a mechanism for real-time electronic prior authorization decisions for routinely approved items and services 
2. Requiring plans to respond to prior authorization requests within 24 hours for urgently needed care 
3. Requiring detailed transparency metrics 

The regulation is expected to play a key role in lowering the flawed score of $16 billion that the Congressional Budget Office (CBO) prepared in advance of the Improving Seniors’ Timely Access to Care Act passing the House of Representatives in 2022. If the final prior authorization regulation mirrors the provisions within the Improving Seniors’ Timely Access to Care Act, the CBO score will be dramatically lower, thus improving its odds of full passage in the House and Senate.  

The AMA applauds the Ways and Means Committee for advancing this key reform to prior authorization processes and will work diligently to ensure Congress passes the Improving Seniors’ Timely Access to Care Act in a bipartisan fashion.

On July 27, Representatives Michael Burgess, MD (R-TX) and Vicente Gonzalez (D-TX) reintroduced H.R. 4968, the Getting Over Lengthy Delays in Care as Required by Doctors (GOLD CARD) Act of 2023 in the 118th Congress. This important bipartisan legislation exempts physicians from Medicare Advantage (MA) plan prior authorization requirements so long as 90% of the physicians’ pre-certification requests were approved in the preceding twelve months. MA plan-issued gold cards are applicable only to items and services (excluding drugs) and remain in effect for at least a year. The legislation is based on a similar law enacted in Texas that took effect in 2021.  

Following direct advocacy from the AMA, the GOLD CARD Act also establishes numerous processes to ensure that MA plans cannot inappropriately revoke this exception to prior authorization practices.  Although permitted to rescind the exemption, MA plans must demonstrate that less than 90% of claims submitted during a 90-day plan period would not have received prior authorization. This 90-day review must be extended until at least 10 claims are ultimately provided. Services that are initially denied and pending appeal for at least 30-days are required to be considered “approved” with respect to the 90% threshold. The bill also explicitly excludes services impacted by a change in coverage determinations that were submitted during the 90-day lookback period. Most importantly, MA plan physicians who review the potential gold card rescission are required to be actively engaged in the practice of medicine in the same or similar specialty as the physician under review, have knowledge about the specific service in question and possess a current, nonrestricted license in the same state as the furnishing physician. Physicians who possess the gold card can also appeal any attempt to rescind the exemption.   

“Prior authorization continues to serve as a chief frustration for physicians due to its excessive use, opacity, responsibility for delaying and denying patient care, and direct correlation with poorer health care outcomes,” said AMA President Jesse M. Ehrenfeld, MD, MPH. “The GOLD CARD Act is an important step to right-sizing these insurance-created obstacles to care for Medicare Advantage patients. The American Medical Association supports federal legislation that exempts physicians with high prior authorization approval rates from these harmful and burdensome requirements. One can almost hear the bureaucratic red tape being cut—a rare sound coming from D.C. We commend Reps. Michael Burgess, MD (R-TX) and Vicente Gonzalez (D-TX) for introducing this bipartisan bill that will help reduce physician burnout and improve patient satisfaction.” 

The AMA recently joined the American Hospital Association, America’s Health Insurance Plans, and Blue Cross Blue Shield Association in a sign-on letter (PDF) urging CMS to not proceed with implementing attachment standards for electronic prior authorization (PA) following the release of two conflicting regulatory proposals in Dec. 2022. In the first rule, CMS proposed use of HL7 Fast Healthcare Interoperability Resources (FHIR) application programming interfaces (APIs); the AMA’s comments (PDF) on these provisions were generally supportive. A second rule proposed use of different standards for electronic PA—X12 and HL7 clinical document transactions.  

In both its initial comment letter (PDF) on the attachments rule and the more recent joint letter, the AMA urged CMS to not proceed with mandating attachment standards for PA, as this would require physicians to use two different technologies and workflows for PA based on plan type—leading to increased practice hassles and technology costs. However, the AMA reiterated its strong, ongoing support for PA reform and expressed appreciation for CMS’ efforts to reduce administrative burdens and ensure patients’ timely access to care. 

With the United States facing an ongoing shortage of physicians, especially in rural and underserved areas, and an underlying need to diversify the workforce, Representatives Brad Schneider (D-IL), Don Bacon (R-NE), Sylvia Garcia (D-TX) and David Valadao (R-CA), along with a bipartisan group of 48 members of Congress, introduced H.R. 4942, the Conrad State 30 and Physician Access Reauthorization Act, on July 27. The House bill is identical to legislation introduced by Senators Klobuchar (D-MN) and Susan Collins (R-ME), S. 665, on March 6 that, to date, has garnered 19 bipartisan cosponsors. Absent congressional activity, the Conrad 30 program expires on Oct. 1.   

Currently, physicians from other countries working in the United States on J-1 visas are required to return to their country of origin upon conclusion of their residency for two years before they can apply for another visa or a green card. Under the Conrad 30 program, each individual state is granted 30 waivers to allocate to physicians permitting them to forgo the requirement to return to their country of origin so long as they’re willing to work in a medically underserved community for three years.   

In addition to reauthorizing the program for an additional three years, the Conrad State 30 and Physician Access Reauthorization Act outlines a process to gradually increase the total number of waivers per state, mandates additional transparency in employment contract terms, permits greater immigration flexibilities for spouses and children of participating physicians, and requires an annual report from the U.S. Citizenship and Immigration Services to the Department of Health and Human Services on the annual utilization of the waivers in hopes of better informing rural states how to make full use of the program. To ease the current per country backlog, the legislation also authorizes physicians who practice in underserved areas or Veteran’s Affairs facilities for five years to receive priority access within the green card system. The AMA was joined by the Federation of American Hospitals, National Rural Health Association, the American Academy of Neurology and Association of American Medical Colleges, as proud supporters of this bipartisan legislation.  

Representatives Mike Lawler (R-NY) and Shri Thanedar (D-MI) introduced a different bill, H.R. 4875, the Doctors in Our Borders Act, on July 25 to address a smaller component of the Conrad 30 program.  H.R. 4875 would increase the number of Conrad slots available for each state from 30 to 100. The AMA supports H.R. 4875, as well, and looks forward to working with Congress to enact meaningful legislative changes to the Conrad 30 program.

The AMA recently sent a letter of support (PDF) for S. 712, the Connected MOM Act introduced by Senators Cassidy (R-LA) and Hassan (D-NH). This legislation would take the important step of requiring CMS to send a report to Congress that identifies barriers to coverage of remote physiologic devices (e.g., pulse oximeters, blood pressure cuffs, scales, blood glucose monitors) under state Medicaid programs to improve maternal and child health outcomes for pregnant and postpartum women. This bipartisan legislation would also require CMS to update state resources, such as state Medicaid telehealth toolkits, to align with evidence-based recommendations to help decrease maternal mortality and morbidity.  

Medicaid paid for almost half of all births nationally in the U.S. in 2018, and it plays a critical role in providing maternity-related services, covering the vast majority of births for women of color and women living in rural areas. Technology-enabled devices when coupled with telehealth have played a critical role in keeping patients healthy during the pandemic and ensuring access to care for patients in rural and underserved areas. This same technology is critical to addressing maternal mortality and morbidity by helping screen new mothers for high blood pressure and related treatable and preventable conditions like preeclampsia that lead to unnecessary and avoidable maternal deaths and adverse health outcomes.  

The AMA is focused on supporting legislation like the Connected MOM Act which will make a meaningful difference in addressing the unacceptably high rate of maternal mortality in the U.S., especially for women of color who are disproportionately impacted by a rate of 3:1 when compared to their white counterparts. Telehealth and remote patient monitoring are a critical part of the future of medicine, and will help ensure effective, efficient and equitable delivery of health care in the U.S. The AMA is committed to tackling the issues surrounding maternal mortality and morbidity and supporting legislation that embraces technology that promotes prevention and equity for patients regardless of their zip code. The AMA looks forward to working with Congress to see this important legislation advance. 

On July 28, CMS released updated data on the reinstatement of Medicaid eligibility checks and disenrollments, which resumed on March 31, 2023, following a freeze during the COVID-19 pandemic. According to the data, so far 2.2 million Medicaid/CHIP enrollees have gone through the renewal process in 18 states that completed renewals during the first month of the unwinding—April 2023. Just over one million (45.5%) had their coverage renewed while more than 700,000 (32.2%) had their coverage terminated. 22% of cases were still pending.  

54,000 individuals previously covered by Medicaid or CHIP enrolled in a marketplace plan. Procedural reasons were behind 79% of terminations, while 21% lost coverage based on ineligibility determinations. In an accompanying letter (PDF) to state governors, HHS Secretary Xavier Becerra emphasized that many children may be eligible for CHIP coverage even if their parents are no longer eligible for Medicaid, and urged states to take advantage of ex parte renewals, which involves automatically renewing beneficiaries based on alternative data sources.  

According to the Kaiser Family Foundation Medicaid Enrollment and Unwinding Tracker, which uses more current data from 41 states and District of Columbia, as of Aug. 7—slightly more than four months into the unwinding—nearly four million (3,898,000) total Medicaid enrollees had been disenrolled from the program. Renewal rates were higher at 61%, but KFF also underscored that disenrollments are undercounted since not all states report disenrollment data. Of the 39% who were disenrolled, the sizable majority (75%) were disenrolled for procedural reasons and about a quarter due to determinations of ineligibility. Disenrollment rates varied widely across states, with Texas having the highest at 82% and Wyoming the lowest at only 8%. Based on data from the eight states reporting age, children made up approximately one-third (31%) of those disenrolled.

• Aug. 11, 2023: Medicare Payment Reform Advocacy Update
• Aug. 11, 2023: State Advocacy Update