The bill mandates that prior authorization decisions under Medicare be determined by physicians. It defines core terms and lays out a framework for how preauthorization should operate, including who can make determinations, what criteria must be used, and how information must be shared.
Section 3 imposes contract requirements on Medicare administrative contractors, Medicare Advantage plans, and prescription drug plans to base decisions on medical necessity and written criteria, with clinician input and public-facing transparency.
At a Glance
What It Does
Requires MACs, MA plans, and PDPs to base preauthorization decisions on medical necessity and written clinical criteria; ensures physician input in establishing criteria; requires posting of criteria and determinations on plan websites; imposes notice and data-disclosure requirements.
Who It Affects
Medicare Administrative Contractors, Medicare Advantage plans, and Prescription Drug Plan sponsors; health care providers submitting requests; practicing physicians who advise on criteria; and Medicare beneficiaries.
Why It Matters
Creates a standardized, physician-led framework for preauthorization to reduce delays, align determinations with clinical practice, and increase transparency for providers and patients.
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What This Bill Actually Does
Section 1 establishes the act’s short title, signaling its aim to reduce delays in care by changing how preauthorization decisions are made under Medicare. Section 2 provides definitions for key terms used throughout the bill, including medical necessity, authorization, clinical criteria, adverse determinations, and the various programs and plans affected (MACs, MA plans, PDPs).
These definitions tie together who makes decisions and what standards apply. Section 3 sets out the contract requirements that MACs, MA plans, and PDP sponsors must follow once they have a contract in place (or when a contract is amended 90 days after enactment).
The requirements center on ensuring decisions are rooted in medical necessity, based on written clinical criteria, and informed by input from actively practicing physicians not employed by the plan. The section also requires publicly accessible posting of current criteria and preauthorization rules, a 60-day advance notice for new requirements, and the publication of determinations data by plan type and category.
Finally, it requires that all preauthorizations and adverse determinations be made by physicians licensed in the state and board-certified or eligible in the relevant specialty, under the direction of medical directors responsible for the care. This structure is designed to minimize non-clinical delays and improve consistency and transparency across the Medicare ecosystem.
The Five Things You Need to Know
The bill requires MACs, MA plans, and PDPs to base preauthorization decisions on medical necessity and written criteria.
Written criteria must be based on nationally recognized standards, reflect community practice, and be updated at least annually.
Input from actively practicing physicians not employed by the plan must be obtained before establishing or changing criteria.
All determinations must be made by physicians licensed in the state and board-certified/eligible in the provider’s specialty.
Plans must post current preauthorization requirements and criteria and provide 60 days’ notice before new rules take effect.
Section-by-Section Breakdown
Every bill we cover gets an analysis of its key sections.
Short title
This section designates the act as the Reducing Medically Unnecessary Delays in Care Act of 2025, signaling a shift toward physician-led preauthorization decisions within Medicare.
Definitions
Key terms are defined to align the decision framework: adverse determination, authorization, clinical criteria, final adverse determination, health care service, medically necessary health care service, Medicare Administrative Contractor, Medicare Advantage plan, preauthorization, and prescription drug plan. The definitions establish who makes decisions, what standards apply, and how care is categorized for coverage and payment.
Contract requirements for prior authorization decisions
This is the substantive core. It requires that any restriction, preauthorization, adverse determination, or final denial used for coverage or payment be based on medical necessity or appropriateness and written criteria. If no independently developed evidence-based standard exists for a service, denial cannot be based solely on the lack of such a standard. The section also mandates input from actively practicing physicians not employed by the plan, ensures written criteria meet national standards and accreditation norms, and requires plans to apply criteria consistently. In addition, plans must post all current preauthorization requirements and criteria on their websites in accessible language, provide 60 days’ notice before new or amended requirements, and publish statistics on determinations by category. Finally, all determinations must be made by physicians with current licenses and board certification/eligibility in the provider’s specialty, under the direction of medical directors responsible for service provision.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Medicare beneficiaries who experience fewer unnecessary delays and better alignment of care with physician judgment.
- Actively practicing physicians who contribute to the development and refinement of clinical criteria.
- Hospitals and clinics that rely on timely preauthorization decisions for patient management.
- Medicare Administrative Contractors and Medicare Advantage plans that implement transparent, evidence-based standards.
- PDP sponsors and the broader Medicare ecosystem that benefits from standardized, predictable decision-making.
Who Bears the Cost
- MACs, MA plans, and PDPs must implement and maintain new criteria, input processes, and posting requirements, incurring administrative costs.
- Plans must evolve IT systems to publish criteria, decisions, and denial reasons in accessible formats.
- Physician time and resources may be required to provide input on criteria and participate in non-employment-based input processes.
- CMS oversight and monitoring obligations could require additional staffing and reporting.
- Potential costs associated with training and educating providers about new rules and timelines.
Key Issues
The Core Tension
Standardizing preauthorization criteria and mandating physician-led decisions must be balanced against the need for timely decisions and practical workflow in diverse care environments; this creates a central dilemma between clinical rigor and administrative efficiency.
The bill strives for tighter alignment between clinical practice and preauthorization decisions, but it raises implementation questions. Translating broad concepts like 'national standards' and 'community standards' into uniformly applicable criteria across diverse specialties and settings may be challenging.
The requirement that physicians provide input and that decisions be physician-made could extend timelines if consultation processes become bottlenecks, even as overall goals are to reduce delays. The act also relies on robust posting and data-sharing practices; without sustained funding and administrative support, there is a risk that websites and data portals lag behind actual practice, reducing the intended transparency.
Finally, the text does not specify enforcement mechanisms or funding, leaving practical questions about compliance, auditing, and remedies to future rulemaking.
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