A majority of the House and Senate sent letters to the Secretary of Health and Human Services (HHS) and Administrator of the Centers for Medicare and Medicaid Services (CMS). The letters, signed by 233 Representatives and 61 Senators, prompted the Administration to finalize its proposed rule that would reform prior authorization practices in the Medicare Advantage program. CMS has set a December 2025 date for finalizing its rule but says it will publish it sooner if it can.

Advocates in Congress think the government needs to set stricter rules to enforce against health insurers’ slow-walking decisions on whether to approve treatments for patients. Last year after the House bill easily passed to reform the “prior authorization” process, it stalled in the Senate when  the Congressional Budget office projected the measure would cost $16 billion. “The proposed CMS rules make huge strides forward for seniors,” Rep. Suzan DelBene (D-Wash.), the lead author of the letter and sponsor of last year's bill, told POLITICO. “But we think it needs to go further.” Lawmakers are calling on CMS to add several provisions to the regulation to align it more with the legislation, including:

• Real-time prior authorization for routine matters 
• A 24-hour deadline for Medicare Advantage plans to answer prior authorization requests for “urgently needed care” 
• More detailed transparency metrics 

Delays in care can put patients at risk. A lack of standards among insurers can hamper the process.

“The CBO score was an unfortunate roadblock last Congress, especially in the Senate. We shouldn’t let a CBO score get in the way of helping seniors access the care they are already entitled to under Medicare,” DelBene told POLITICO. “The hope is that once the rule is finalized and we get quality policy in place, hopefully with the real-time decision-making and faster response deadlines components, it will also bring the score down.”