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Requires Medicare contractors, Medicare Advantage organizations, and Part D sponsors to put explicit limits on how prior authorization and utilization review work: they must base denials or restrictions on written clinical criteria and medical necessity, get practicing physician input before creating or changing criteria, post preauthorization rules and denial statistics online, and ensure physician reviewers are licensed and board certified (or eligible) in the same specialty as the treating provider. These requirements apply to new contracts signed 90 days after enactment and are intended to reduce medically unnecessary delays in care and increase transparency and consistency.
The bill strengthens beneficiary protections, transparency, and clinician-led coverage decisions for Medicare, but it increases administrative costs, risks slower approvals in some areas, and raises legal and program-spending risks that could affect access and taxpayers.
Medicare beneficiaries (including Part D enrollees and patients with chronic conditions) gain clearer, legally grounded protections because key terms (e.g., 'medically necessary', 'authorization') and requirements that coverage decisions rely on written clinical criteria are defined, reducing arbitrary denials and increasing predictability of coverage decisions.
Providers, plans, and contractors get a common set of definitions and must publish preauthorization rules and approval/denial statistics, improving transparency and helping hospitals, clinicians, and plans navigate utilization review and appeals processes.
Coverage criteria and decisions are likely to be more clinically relevant because entities must solicit input from actively practicing, board-certified (or eligible) physicians in the service area and rely on specialty-appropriate reviewers, reducing non-clinical decision‑making.
Insurers, contractors, and plans (and potentially Medicare administration) will face increased administrative and compliance costs to implement the new definitions, publication requirements, and reviewer rules, which could raise program administrative spending or be passed through to taxpayers and beneficiaries.
Requiring specialty-matched physician reviewers and more specific reviewer qualifications could strain reviewer availability—especially in rural areas—and slow preauthorization turnaround times, delaying access to care for some beneficiaries.
Prohibiting denial solely because no evidence-based standard exists may expand coverage for procedures with limited evidence, increasing utilization and program costs that could affect taxpayers and Medicare premiums.
Introduced March 27, 2025 by Mark E. Green · Last progress March 27, 2025