Congress has been in recess for the month of October, with lawmakers not scheduled to return until November 12, the week following Election Day.

Over the recess, the Improving Seniors’ Timely Access to Care Act (H.R. 8702) surpassed 218 cosponsors in the U.S. House of Representatives – a critical milestone representing the support of a bipartisan majority of the chamber. The Senate legislation (S.4532) previously achieved this threshold and currently has the endorsement of 55 senators. The bill, which would streamline and standardize the use of prior authorization by Medicare Advantage (MA) plans, was unanimously passed by the House last Congress but has not yet been taken up in the 118th Congress.

In related news, the Senate Permanent Subcommittee on Investigations has released a report detailing the challenges faced by Medicare Advantage (MA) enrollees in accessing care, along with an analysis of the volume and scope of prior authorization denials for specific types of treatment. The analysis is based on over 280,000 pages of documents obtained from UnitedHealthcare, Humana, and CVS, which collectively serve around 60% of all MA patients. The investigation found that these companies denied prior authorization requests for post-acute care at significantly higher rates compared to other types of care. Additionally, from 2020 to 2022, the use of prior authorization increased notably as companies began to use technology to automate the prior authorization process. The report indicates that while the subcommittee is still examining the use of predictive technologies by MA insurers, the initial data is concerning, “regardless of whether the decisions reflected in the data were the result of predictive technology or human discretion,” and suggesting “MA insurers are intentionally targeting a costly but critical area of medicine – substituting judgment about medical necessity with a calculation about financial gain.”

RNS joined more than 250 other organizations urging congressional leadership to include the Safe Step Act (S. 652/H.R. 2630) in any pharmacy benefit manager (PBM) reform legislation or end-of-year package that is considered by Congress in the coming weeks. The bill would create commonsense patient safeguards around step therapy in employer-sponsored plans, establishing a transparent, convenient process to request step therapy exceptions, with a timeline for appeals. Importantly, the bill codifies exceptions to step therapy in five specific circumstances, including when a patient’s condition is stable on a different medication or when the medication required by the insurer is expected to be ineffective for the patient. The Safe Step Act was attached to the Pharmacy Benefit Manager Reform Act (S. 1339) as reported out of the Senate Health, Education, Labor, and Pensions Committee with bipartisan support last year.

Lawmakers will have approximately 20 working days during the lame duck session following next week’s elections to accomplish a number of major policy priorities that await congressional action, including but not limited to passage of fiscal year 2025 appropriations and avoiding a government shutdown, as well as consideration of a supplemental disaster aid package.

As a reminder, if you’d like to become more involved in our advocacy work, please drop us a line: advocacy@rnsnurse.org.