HR 2433119th CongressIn Committee

Reducing Medically Unnecessary Delays in Care Act of 2025

Introduced: Mar 27, 2025

Standard Summary

Comprehensive overview in 1-2 paragraphs

The Reducing Medically Unnecessary Delays in Care Act of 2025 would require Medicare prior-authorization decisions to be determined by physicians. Specifically, contracts with Medicare Administrative Contractors (MACs), Medicare Advantage plans, and prescription drug plans (PDPs) would need to base preauthorization and adverse determinations on medical necessity, with written, evidence-based clinical criteria that are developed with input from practicing physicians. The bill emphasizes transparency (posting criteria and decision data on websites), advance notice of new requirements (at least 60 days), and that all determinations be made by licensed physicians who are board-certified or board-eligible in the same specialty as the provider managing the patient’s condition. The overall aim is to reduce delays in care by ensuring physician oversight and standardized, transparent criteria for prior authorization decisions. Key provisions focus on tying preauthorization decisions to medical necessity and current clinical criteria, requiring physician input in creating those criteria, mandating public posting of requirements, ensuring changes are communicated in advance, and guaranteeing physician-led determinations with appropriate medical oversight.

Key Points

1Medical necessity and written clinical criteria: All restrictions, preauthorizations, adverse determinations, and final adverse determinations used to authorize or deny care must be grounded in medical necessity or appropriateness and use written clinical criteria.
2Physician input and independent standards: Before establishing or altering written clinical criteria for preauthorization, MACs/MA plans/PDPs must obtain input from actively practicing physicians in the service area, representing major specialties and board-certified/eligible status, including physicians not employed by the plan.
3Written criteria and standards: Criteria must be based on nationally recognized standards, meet accreditation standards, reflect community standards of care, ensure quality and access, be evidence-based, allow case-by-case deviations when justified, and be reviewed/updated at least annually.
4Transparency and notices: Current preauthorization requirements and the written clinical criteria must be posted on plan websites in clear language; if a new or amended preauthorization requirement is planned, providers must receive at least 60 days’ written notice before implementation and the change must be posted online.
5Determinations by physicians: All preauthorizations and adverse determinations must be made by physicians with valid licenses, board-certified or eligible in the same specialty as the provider who manages the patient’s condition, and the adverse determination must be made under the clinical direction of a licensed medical director.

Impact Areas

Primary group/area affected- Medicare beneficiaries whose care requires prior authorization and the clinicians who manage their care. The bill seeks to align MA, MAC, and PDP decision-making with medical necessity and physician oversight, potentially reducing delays in access to needed services.Secondary group/area affected- Medicare Administrative Contractors, Medicare Advantage plans, and prescription drug plans. These entities would face new requirements for criteria development, physician input, transparency, and physician-led determinations, along with reporting and update obligations.Additional impacts- Administrative/operational changes: Implementation of standardized, physician-informed criteria; website posting requirements; and monitoring of determinations and denials by specialty and indication.- Quality and access considerations: Emphasis on evidence-based standards and community-appropriate care could improve consistency and potentially enhance access to medically necessary services.- Potential challenges: Increased time and resource needs for physician input and ongoing criteria updates; potential implications for plan flexibility in applying preauthorization standards; need to manage transition with 60-day notice periods for changes.

Generated by gpt-5-nano on Nov 18, 2025