What is the Improving Seniors' Timely Access to Care Act?
1. What does the Improving Seniors' Timely Access to Care Act do?
The Improving Seniors' Timely Access to Care Act is bipartisan legislation that aims to modernize prior authorization for Medicare Advantage plans by:
● Mandating electronic prior authorization (ePA).
● Standardizing approval timelines to prevent delays in patient care.
● Requiring FHIR-based data exchange for seamless interoperability.
● Increasing transparency by requiring public reporting of authorization metrics.
Why It Matters: Medicare Advantage plans and PBAs managing prior authorization must comply with new ePA technology mandates and faster decision-making requirements.
2. Who does the Improving Seniors' Timely Access to Care Act apply to?
● Medicare Advantage (MA) plans
● Medicare Advantage Organizations (MAOs)
● Pharmacy Benefit Administrators (PBAs) managing prior authorizations for MA plans
● Healthcare providers interacting with Medicare Advantage payers
3. Why was this law proposed?
Prior authorization delays impact patient care. Studies show:
● 94% of physicians experience delays due to manual prior authorization processes.
● 24% of doctors report that these delays caused serious adverse events.
● 80%+ of seniors find prior authorization to be a barrier to timely care.
This law eliminates excessive delays by digitizing approvals and automating workflows to improve care for seniors.
Prior Authorization Compliance for Medicare Advantage Plans
4. What changes does the Improving Seniors' Timely Access to Care Act introduce to prior authorization?
● Mandatory Electronic Prior Authorization (ePA): Eliminates faxes and manual reviews.
● Faster Turnaround Times:
○ Urgent requests: 72-hour approval deadline
○ Standard requests: 7-day approval deadline (reduced from 14 days)
● Real-Time Approvals for Certain Procedures: Auto-approvals for frequently approved services
● FHIR API Integration for Seamless Data Exchange
5. How do the new prior authorization response times affect Medicare Advantage payers?
Payers must comply with shortened response windows:
● Urgent prior authorizations must be approved within 72 hours
● Standard prior authorizations must be processed within 7 days (previously 14)
● Real-time decision-making required for routine services with consistent approval
FHIR API & Electronic Prior Authorization (ePA) for Payers
6. What is the FHIR API requirement in the act?
FHIR (Fast Healthcare Interoperability Resources) APIs must be implemented by Medicare Advantage payers and PBAs to:
● Automate electronic prior authorization (ePA)
● Provide real-time prior authorization status updates to providers
● Ensure seamless interoperability between payers, providers, and PBMs
7. How does electronic prior authorization (ePA) improve Medicare Advantage workflows?
ePA technology eliminates:
- Manual paperwork & fax-based approvals
- Long response times & administrative burden
- Delays in senior patient care
Our Solution: Our AI-powered ePA software reduces approval delays, integrates with payer systems, and automates compliance tracking for Medicare Advantage plans.
Medicare Advantage Transparency & Reporting Requirements
8. What prior authorization data must Medicare Advantage payers report publicly?
By January 1, 2027, Medicare Advantageplans must report:
● Total prior authorization requests.
● Approval & denial rates.
● Average response times for approvals and denials.
● Top services requiring prior authorization.
Implementation Timeline &Compliance for Medicare Advantage Payers
9. When do Medicare Advantage plans need to comply with the Improving Seniors' Timely Access to Care Act?
● January 1, 2026:
○ Implement FHIR-based APIs for real-time data exchange
○ Automate ePA for Medicare Advantage prior authorizations
○ Meet new 72-hour & 7-day turnaround times
● January 1, 2027:
○ Public prior authorization reporting requirements take effect
10. What are the risks of non-compliance?
Failure tocomply with Medicare Advantage prior authorization mandates could result in:
- CMS enforcement actions or penalties
- Increased provider dissatisfaction& network issues
- Higher operational costs due to manual inefficiencies
For Medicare Advantage Payers: Our AI-driven prior authorization platform ensures fast approvals, reduced costs, and CMS compliance.
Final Thoughts: Preparing for Medicare Advantage Prior Authorization Changes
The Improving Seniors’ Timely Access to Care Act will transform prior authorization in Medicare Advantage, requiring ePA technology, faster approvals, and real-time transparency.
