Doctor Knows Best Act of 2025
The Doctor Knows Best Act of 2025 would prohibit health plans and federal health care programs from using common administrative controls on covered services. Specifically, it would bar group health plans and health insurance issuers offering group or individual coverage from requiring prior authorization, using utilization management techniques (including step therapy or fail-first protocols), or performing medical necessity reviews on any item or service that is covered under the plan. Beginning January 1, 2026, federal health care programs would face the same prohibition. The aim is to simplify access to care by eliminating these gatekeeping processes, but it could also lead to higher utilization and spending since coverage would not be conditioned on medical necessity reviews or stepped treatment protocols.
Key Points
- 1Private insurers: The act adds a new Section 2730 to the Public Health Service Act, prohibiting group health plans and health insurance issuers offering group or individual coverage from imposing prior authorization, utilization management (including step therapy), or medical necessity reviews on covered items or services.
- 2Federal programs: Starting January 1, 2026, Federal health care programs (including Medicare/Medicaid-related programs and federal health programs described in the act) would be barred from using prior authorization, utilization management techniques, or medical necessity reviews for covered items or services.
- 3Effective date: The prohibition applies to plan years beginning on or after January 1, 2026 for private plans and to the specified federal programs beginning that same date.
- 4Legislative vehicle: The bill would amend the Public Health Service Act; it was introduced in the House and referred to the Committee on Energy and Commerce and the Committee on Oversight and Government Reform.
- 5Policy effect: By removing these gatekeeping tools, providers and patients would have quicker access to covered services but could face higher overall costs and less control over utilization.