Sponsors (17)
This is not an official government website.
Copyright © 2026 PLEJ LC. All rights reserved.
Requires Medicare contractors, Medicare Advantage organizations, and Part D plan sponsors to use clear, written clinical criteria and medical‑necessity standards for prior authorization and utilization review, post those criteria and approval/denial statistics publicly, obtain input from practicing board‑certified physicians before adopting or changing criteria, and ensure clinical decisions are made by appropriately licensed, board‑certified (or eligible) physicians. The rules apply to new contracts entered into 90 days after the law takes effect and set notice, posting, and review-frequency requirements but do not authorize new spending. The goal is to reduce medically unnecessary delays in care by increasing transparency, standardizing decisionmaking, and requiring physician involvement in prior authorization and adverse determinations.
The bill increases clarity, clinical oversight, and transparency in Medicare coverage decisions—reducing arbitrary denials and improving accountability—at the cost of higher administrative burdens, potential delays from reviewer requirements, reduced plan flexibility, and risks of higher utilization or legal disputes.
Medicare beneficiaries (especially people with chronic conditions) will face fewer arbitrary denials because the bill defines 'medically necessary' and requires coverage decisions based on written clinical criteria tied to medical necessity.
Providers and plans get a common set of definitions (e.g., 'authorization', 'clinical criteria') and clearer rules, which can streamline utilization review, appeals, and reduce inconsistent interpretations across payers.
Coverage criteria are likely to be more clinically relevant because plans must obtain input from actively practicing, board-certified (or eligible) specialty physicians before creating or materially changing criteria, reducing non-clinical decision-making.
Insurers, Medicare contractors, and plans will face increased administrative and compliance costs to align policies with the new statutory definitions and transparency requirements, which could raise Medicare program costs or plan administrative overhead.
Requiring specialty-matched, actively practicing physician reviewers may strain reviewer availability—particularly in rural areas—and slow preauthorization turnaround times, delaying patient care.
Tighter statutory definitions of 'medically necessary' could limit plans' flexibility to adapt criteria to new evidence or individual clinical scenarios, potentially reducing appropriate individualized care.
Introduced March 27, 2025 by Mark E. Green · Last progress March 27, 2025