Medicare Advantage Plans Must Digitize Prior Authorization by 2028 and Publish Approval Rates

The “Improving Seniors’ Timely Access to Care Act of 2025” is a serious attempt to pull the notoriously frustrating prior authorization (PA) process in Medicare Advantage (MA) plans out of the fax machine era and into the 21st century. Starting in 2028, MA plans must use a standardized electronic PA system, moving away from the current patchwork of faxes, phone calls, and proprietary portals. This isn’t just about going digital; it’s about transparency and speed, especially for the 30 million-plus seniors relying on MA plans for coverage.

The Clock is Ticking: Digital Deadline for Plans

If you’ve ever had a doctor’s appointment delayed because the insurance company was taking its sweet time approving a scan or a procedure, you know the pain of prior authorization. This bill aims to fix that by setting a firm deadline for plans to implement an electronic system that can securely send and receive PA requests and documentation. For plan years beginning in 2028, MA plans have to be fully electronic, and the Secretary is tasked with setting the technical standards to ensure these systems actually talk to each other correctly. For providers—from the family doctor to the specialist—this standardization should eventually mean less administrative hassle and a faster turnaround on care, though the transition period will likely involve some growing pains as everyone adapts to the new systems.

Sunlight is the Best Disinfectant: Public Scorecards

Starting in 2027, MA plans are going to have to get radically transparent about how they use prior authorization. They must report a massive amount of data annually, including the percentage of requests approved versus denied, how many denials were overturned on appeal, and the average time it takes to get a decision. Crucially, they also have to report how often they use technology like AI or machine learning to make these decisions, and what the approval rates are when using that tech. The government will then take this data and publish it publicly on the CMS website, essentially giving every plan a public scorecard. This is a game-changer for accountability: if a plan is denying 30% of requests while its competitor is denying 5%, that difference will be visible to everyone, including future enrollees and the doctors who contract with them.

Faster Decisions and Clearer Rules

Beyond transparency, the bill gives the Secretary new power to enforce faster response times for PA requests. While there are existing rules, this legislation allows the government to set specific, tighter timeframes—potentially 24 hours for expedited requests or even real-time decisions for routine services. For a senior needing urgent care, shaving days off a waiting period can be critical. Furthermore, plans must now share the specific criteria they use to approve or deny services with contracting providers and, upon request, with the enrollee themselves. This means no more guessing games; patients and their doctors will know the rulebook before they submit the request.

Real-World Impact: Who Pays and Who Benefits?

This bill is a clear win for Medicare Advantage enrollees and the healthcare providers who serve them, promising quicker access to necessary care and less time spent on administrative limbo. However, the changes come with a significant price tag for the MA plans themselves. They face substantial, mandated costs to develop and implement these new electronic systems by the 2028 deadline. While the intent is to reduce administrative waste, there’s always a risk that these compliance costs could eventually be passed down to enrollees through higher premiums or reduced benefits, although the bill text doesn’t address that directly. Ultimately, this legislation forces a modernization that should streamline care, but the true measure of its success will be whether plans use the new transparency requirements to genuinely improve patient access or simply to manage their public image.