Reducing Medically Unnecessary Delays in Care Act of 2025
This bill requires Medicare coverage decisions, including prior authorization requirements and adverse coverage decisions, to be based on written clinical criteria that is developed in consultation with physicians.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2433 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 2433
To ensure that prior authorization medical decisions under Medicare are
determined by physicians.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 27, 2025
Mr. Green of Tennessee (for himself, Mr. Murphy, Ms. Schrier, Mr. Joyce
of Pennsylvania, Mr. McCormick, Mr. Harris of Maryland, Mr. Burchett,
Mr. Babin, Mrs. Miller-Meeks, and Mr. Kennedy of Utah) introduced the
following bill; which was referred to the Committee on Ways and Means,
and in addition to the Committee on Energy and Commerce, for a period
to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To ensure that prior authorization medical decisions under Medicare are
determined by physicians.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Reducing Medically Unnecessary
Delays in Care Act of 2025''.
SEC. 2. DEFINITIONS.
In this Act:
(1) Adverse determination.--The term ``adverse
determination'' means a decision by a medicare administrative
contractor, Medicare Advantage plan, or prescription drug plan
that administers prior authorization programs under the
Medicare program under title XVIII of the Social Security Act
or such plan that the health care services furnished or
proposed to be furnished to an individual entitled to benefits
or enrolled under the Medicare program are not medically
necessary, or are experimental or investigational; and benefit
coverage under such program or plan for such services is
therefore denied, reduced, or terminated.
(2) Authorization.--The term ``authorization'' means a
determination by a medicare administrative contractor, Medicare
Advantage plan, or prescription drug plan that administers
prior authorization programs under the Medicare program under
title XVIII of the Social Security Act or such plan that a
health care service has been reviewed and, based on the
information provided, satisfies the utilization review entity's
requirements for medical necessity and appropriateness and that
payment will be made under the Medicare program under title
XVIII of the Social Security Act or such plan for that health
care service.
(3) Clinical criteria.--The term ``clinical criteria''
means the written policies, written screening procedures, drug
formularies, or lists of covered drugs, decision rules,
decision abstracts, clinical protocols, practice guidelines,
and medical protocols used by a medicare administrative
contractor, Medicare Advantage plan, or prescription drug plan
to determine the necessity and appropriateness of health care
services.
(4) Final adverse determination.--The term ``final adverse
determination'' means an adverse determination that has been
upheld by a medicare administrative contractor, Medicare
Advantage plan, or prescription drug plan at the completion of
the contractor's appeals process.
(5) Health care service.--The term ``health care service''
means a health care item, service, procedure, treatment, or
prescription drug provided by a facility licensed in the State
involved or provided by a doctor of medicine, a doctor of
osteopathic medicine, or a health care professional licensed in
such State.
(6) Medically necessary health care service.--The term
``medically necessary health care services'' means health care
services that a prudent physician would provide to a patient
for the purpose of preventing, diagnosing, or treating an
illness, injury, disease, or its symptoms in a manner that is--
(A) in accordance with generally accepted standards
of medical practice;
(B) clinically appropriate in terms of type,
frequency, extent, site, and duration; and
(C) not primarily for the economic benefit of the
health plans and purchasers or for the convenience of
the patient, treating physician, or other health care
provider.
(7) Medicare administrative contractor.--The term
``medicare administrative contractor'' means a medicare
administrative contractor with a contract under section 1874A
of the Social Security Act (42 U.S.C. 1395kk-1).
(8) Medicare advantage plan.--The term ``Medicare Advantage
plan'' means a Medicare Advantage plan under part C of title
XVIII of the Social Security Act.
(9) Preauthorization.--The term ``preauthorization''--
(A) means the process by which a medicare
administrative contractor, Medicare Advantage plan, or
prescription drug plan determines the medical necessity
or medical appropriateness of health care services for
which benefits are otherwise provided under the
Medicare program under title XVIII of the Social
Security Act or such plan prior to the rendering of
such health care services, including preadmission
review, pretreatment review, utilization, and case
management; and
(B) includes any requirement that a patient or
health care provider notify the Centers for Medicare &
Medicaid Services prior to providing a health care
service.
(10) Prescription drug plan.--The term ``prescription drug
plan'' means a prescription drug plan under part D of title
XVIII of the Social Security Act.
SEC. 3. CONTRACT REQUIREMENTS FOR PRIOR AUTHORIZATION MEDICAL DECISIONS
FOR MEDICARE ADMINISTRATIVE CONTRACTORS, MEDICARE
ADVANTAGE PLANS, AND PRESCRIPTION DRUG PLANS.
Any contract that applies on or after the date that is 90 days
after the date of the enactment of this Act, between the Secretary of
Health and Human Services and a medicare administrative contractor
under section 1874A of the Social Security Act, a Medicare Advantage
organization under section 1857 of such Act with respect to the
offering of a Medicare Advantage plan, or a PDP sponsor under section
1860D-12 of such Act with respect to the offering of a prescription
drug plan shall require such medicare administrative contractor,
Medicare Advantage plan, or prescription drug plan, respectively, to
comply with each of the following requirements:
(1) Medical necessity.--Any restriction, preauthorization,
adverse determination, or final adverse determination that the
medicare administrative contractor, Medicare Advantage plan, or
prescription drug plan, respectively, places on the provision
of a health care service for the purposes of coverage or
payment of such service under the Medicare program under title
XVIII of such Act, or under such plan, shall be based on the
medical necessity or appropriateness of such service and on
written clinical criteria.
(2) Evidence-based standards.--If no independently
developed evidence-based standards exist for a particular
health care service, the medicare administrative contractor,
Medicare Advantage plan, or prescription drug plan,
respectively, may not deny coverage of the health care service
based solely on the grounds that the health care service does
not meet an evidence-based standard.
(3) Input from physicians.--Prior to establishing, or
substantially or materially altering, written clinical criteria
for purpose of preauthorization review, the medicare
administrative contractor, Medicare Advantage plan, or
prescription drug plan, respectively, shall obtain input from
actively practicing physicians within the service area where
the written clinical criteria are to be employed. Such
physicians must represent major areas of specialty and be
certified by the boards of the American Board of Medical
Specialties or the American Osteopathic Association. The
medicare administrative contractor, Medicare Advantage plan, or
prescription drug plan shall seek input from physicians who are
not employees of the medicare administrative contractor,
Medicare Advantage plan, or prescription drug plan.
(4) Written clinical criteria.--The medicare administrative
contractor, Medicare Advantage plan, or prescription drug plan,
respectively, shall apply written clinical criteria for the
purpose of preauthorization review consistently. Such written
clinical criteria must--
(A) be based on nationally recognized standards;
(B) be developed in accordance with the current
standards of national accreditation entities;
(C) reflect community standards of care;
(D) ensure quality of care and access to needed
health care services;
(E) be evidence based;
(F) be sufficiently flexible to allow deviations
from norms when justified on case-by-case bases; and
(G) be evaluated and updated if necessary at least
annually.
(5) Website posting.--The medicare administrative
contractor, Medicare Advantage plan, or prescription drug plan,
respectively, shall make any current preauthorization
requirements and restrictions readily accessible on its website
to subscribers, health care providers, and the general public.
This includes the written clinical criteria. Such requirements
must be described in detail but also in easily understandable
language.
(6) Notice required for new requirements or restrictions.--
If the medicare administrative contractor, Medicare Advantage
plan, or prescription drug plan, respectively, decides to
implement a new preauthorization requirement or restriction, or
amend an existing requirement or restriction, the medicare
administrative contractor, Medicare Advantage plan, or
prescription drug plan shall provide contracted health care
providers written notice of the new or amended requirement or
amendment no less than 60 days before the requirement or
restriction is implemented and shall ensure that the new or
amended requirement has been updated on the medicare
administrative contractor, Medicare Advantage plan, or
prescription drug plan's website.
(7) Availability of determinations.--The medicare
administrative contractor, Medicare Advantage plan, or
prescription drug plan, respectively, utilizing
preauthorization shall make statistics available regarding
preauthorization approvals and denials for coverage or payment
of health care services under the Medicare program under title
XVIII of the Social Security Act or such plan on their website
in a readily accessible format. The medicare administrative
contractor, Medicare Advantage plan, or prescription drug plan
shall include categories for--
(A) physician specialty;
(B) medication or diagnostic test/procedure;
(C) indication offered; and
(D) reason for denial.
(8) Determinations made by physicians.--The medicare
administrative contractor, Medicare Advantage plan, or
prescription drug plan, respectively, shall ensure that all
preauthorizations and adverse determinations are made by a
physician who possesses a current and valid non-restricted
license to practice medicine in a State, and must be board
certified or eligible under the rules and guidelines of the
American Board of Medical Specialties or American Osteopathic
Association in the same specialty as the health care provider
who typically manages the medical condition or disease or
provides the health care service. The physician must make the
adverse determination under the clinical direction of one of
the medicare administrative contractor's, Medicare Advantage
plan's, or prescription drug plan's medical directors who is
responsible for the provision of health care services and who
is licensed in such State.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
ASSUMING FIRST SPONSORSHIP - Mr. Murphy asked unanimous consent that he may hereafter be considered as the first sponsor of H.R. 2433, a bill originally introduced by Representative Green (TN), for the purpose of adding cosponsors and requesting reprintings pursuant to clause 7 of rule XII. Agreed to without objection.
Llama 3.2 · runs locally in your browser
Ask anything about this bill. The AI reads the full text to answer.
Enter to send · Shift+Enter for new line