Reducing Medically Unnecessary Delays in Care Act of 2025
- Sponsor
- Rep. Green, Mark E. [R-TN-7]
- Committees
- Ways and Means Committee (primary)
- Last action
- Feb 4, 2026
Bottom line
The bill aims to streamline and professionalize the prior authorization process in Medicare by placing medical decision-making authority firmly in the hands of qualified physicians and increasing transparency around the criteria used.
What it actually does
This bill mandates that Medicare administrative contractors, Medicare Advantage plans, and prescription drug plans must ensure all prior authorization and adverse determination decisions are made by licensed, board-certified physicians in the relevant specialty. It also requires these entities to base decisions on written, evidence-based clinical criteria developed with input from non-employee physicians, make these criteria publicly accessible, and provide notice for changes.
Proponents argue
Supporters argue that this bill will reduce unnecessary delays in patient care by ensuring that medical decisions are made by qualified physicians rather than administrative staff, leading to better patient outcomes and reduced administrative burden for providers. They contend that increased transparency in prior authorization criteria will foster trust and efficiency within the healthcare system.
Opponents contend
Opponents might argue that mandating physician review for all prior authorizations could significantly increase administrative costs for plans, potentially leading to higher premiums or reduced benefits for Medicare beneficiaries. They may also contend that existing processes are sufficient and that adding more physician oversight could slow down approvals due to physician availability, rather than speeding them up.
The bill is short and relatively straightforward, allowing for a quick and comprehensive understanding of its provisions.
Section 3(1)
Basing Decisions on Medical Necessity and Written Clinical Criteria
This provision requires that any restrictions, preauthorizations, or denials of coverage or payment by Medicare administrative contractors, Medicare Advantage plans, or prescription drug plans must be based on the medical necessity or appropriateness of the service, as well as on written clinical criteria. This aims to standardize the basis for these decisions.
Supporters argue
Supporters argue this ensures that coverage decisions are rooted in medical science and patient need, rather than purely financial considerations, promoting fair and consistent application of rules.
Critics contend
Critics might argue that defining "medical necessity" can be subjective and that this provision, while seemingly beneficial, might not fundamentally change how plans interpret and apply criteria, potentially leading to ongoing disputes.
Tradeoffs
Balances the need for cost control and utilization management by plans with the imperative to ensure patients receive medically necessary care.
Section 3(2)
Denials Based on Lack of Evidence-Based Standards
This provision states that if no independently developed evidence-based standards exist for a particular health care service, Medicare administrative contractors, Medicare Advantage plans, or prescription drug plans cannot deny coverage solely on the grounds that the service does not meet such a standard. This is intended to prevent denials for innovative or niche treatments where broad standards may not yet exist.
Section 3(3)
Physician Involvement in Developing Clinical Criteria
Before establishing or significantly changing written clinical criteria for prior authorization, plans must obtain input from actively practicing physicians. These physicians must be board-certified or eligible in major specialties and, crucially, must not be employees of the Medicare administrative contractor, Medicare Advantage plan, or prescription drug plan. This aims to ensure criteria reflect current medical practice and are not solely driven by internal plan interests.
Section 3(4)
Requirements for Clinical Criteria Quality and Application
This provision sets out specific requirements for the written clinical criteria used by plans. These criteria must be applied consistently, based on nationally recognized standards, developed in line with national accreditation entities, reflect community standards of care, ensure quality and access, be evidence-based, be flexible for case-by-case deviations, and be evaluated and updated annually. This aims to elevate the quality and fairness of the criteria.
Section 3(5)
Public Accessibility of Prior Authorization Information
This provision mandates that Medicare administrative contractors, Medicare Advantage plans, and prescription drug plans must make their current preauthorization requirements, restrictions, and the underlying written clinical criteria readily accessible on their websites. This information must be described in detail but also in easily understandable language for subscribers, healthcare providers, and the general public.
Section 3(6)
Advance Notice for Changes to Prior Authorization Rules
If a plan decides to implement a new prior authorization requirement or restriction, or amend an existing one, it must provide contracted healthcare providers with written notice at least 60 days before the change takes effect. The plan must also ensure its website is updated with the new information. This aims to give providers sufficient time to adapt to new rules.
Section 3(7)
Public Statistics on Prior Authorization Approvals and Denials
Plans utilizing preauthorization must make statistics available on their website regarding prior authorization approvals and denials. These statistics must be in a readily accessible format and include categories for physician specialty, medication/diagnostic test/procedure, indication offered, and reason for denial. This aims to provide transparency into how prior authorization is actually applied.
Section 3(8)
Physician-Led Prior Authorization and Adverse Determinations
This is a central provision, requiring that all preauthorizations and adverse determinations be made by a physician. This physician must hold a current, valid, non-restricted license in a State and be board-certified or eligible in the same specialty as the healthcare provider typically managing the condition or providing the service. Furthermore, this physician must make the adverse determination under the clinical direction of one of the plan's medical directors who is licensed in the State and responsible for healthcare services.