Reducing Medically Unnecessary Delays in Care Act of 2025 · Introduced in House (2025-03-27)

In this Act:

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.
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.
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.
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.
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.
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—
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
The term Medicare Advantage plan means a Medicare Advantage plan under part C of title XVIII of the Social Security Act.
The term — preauthorization
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—
- be based on nationally recognized standards;
- be developed in accordance with the current standards of national accreditation entities;
- reflect community standards of care;
- ensure quality of care and access to needed health care services;
- be evidence based;

H.R. 2433

Table of contents

SEC. 1. Short title

SEC. 2. Definitions

SEC. 3. Contract requirements for prior authorization medical decisions for Medicare Administrative Contractors, Medicare Advantage plans, and prescription drug plans