HR2433-119

What This Bill Does

The Reducing Medically Unnecessary Delays in Care Act creates contract requirements for Medicare prior authorization. It defines adverse determinations, authorizations, clinical criteria, final adverse determinations, health care services, medically necessary services, Medicare administrative contractors, Medicare Advantage plans, preauthorization, and Part D prescription drug plans. Starting with HHS contracts that apply 90 days after enactment, Medicare administrative contractors, MA plans, and prescription drug plans must base restrictions, preauthorizations, adverse determinations, and final adverse determinations on medical necessity or appropriateness and written clinical criteria. They cannot deny coverage solely because no independently developed evidence-based standard exists. Before establishing or materially changing criteria, they must obtain input from actively practicing, board-certified or board-eligible physicians in relevant specialties who are not plan or contractor employees. Criteria must be nationally recognized, accreditation-consistent, community-standard, evidence-based, flexible for case-by-case deviations, updated at least annually, posted online in understandable language, and accompanied by 60 days' written provider notice for new or changed requirements. Plans and contractors must publish prior authorization approval and denial statistics by specialty, medication or test/procedure, indication, and denial reason, and all preauthorizations and adverse determinations must be made by a current unrestricted licensed physician in the same specialty under medical director clinical direction.

Who Benefits and How

Medicare patients needing prior-authorized care benefit because denials must be tied to medical necessity, written criteria, and same-specialty physician review. Physicians treating Medicare patients benefit from 60-day notice of changed requirements, published criteria, and practicing-physician input before criteria are set. Health care providers benefit from public approval and denial statistics that reveal patterns by specialty, medication, procedure, indication, and denial reason. Patient advocates benefit because plans cannot deny coverage solely because no independently developed evidence-based standard exists.

Who Bears the Burden and How

Medicare Advantage plans must revise prior authorization systems, criteria publication, physician input, statistics reporting, and same-specialty review staffing. Part D prescription drug plans must apply the same contract requirements to drug prior authorization and adverse determinations. Medicare administrative contractors must base restrictions on written clinical criteria and update criteria at least annually. CMS contract staff must add and enforce the new requirements in covered contracts beginning 90 days after enactment.

Key Provisions

• Requires Medicare prior authorization restrictions and adverse determinations to be based on medical necessity and written clinical criteria.
• Prohibits denial solely because no independently developed evidence-based standard exists for a service.
• Requires input from practicing physicians in relevant specialties before establishing or materially changing criteria.
• Requires criteria to be nationally recognized, evidence-based, community-standard, flexible, publicly posted, and updated at least annually.
• Requires 60-day provider notice for new or changed requirements, public approval and denial statistics, and same-specialty physician decision makers.