Us Congress 2025-2026 Regular Session

Us Congress House Bill HB2433 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	I
2	2	119THCONGRESS
3	3	1
4	4	STSESSION H. R. 2433
5	5	To ensure that prior authorization medical decisions under Medicare are
6	6	determined by physicians.
7	7	IN THE HOUSE OF REPRESENTATIVES
8	8	MARCH27, 2025
9	9	Mr. G
10	10	REENof Tennessee (for himself, Mr. MURPHY, Ms. SCHRIER, Mr.
11	11	J
12	12	OYCEof Pennsylvania, Mr. MCCORMICK, Mr. HARRISof Maryland, Mr.
13	13	B
14	14	URCHETT, Mr. BABIN, Mrs. MILLER-MEEKS, and Mr. KENNEDYof
15	15	Utah) introduced the following bill; which was referred to the Committee
16	16	on Ways and Means, and in addition to the Committee on Energy and
17	17	Commerce, for a period to be subsequently determined by the Speaker,
18	18	in each case for consideration of such provisions as fall within the juris-
19	19	diction of the committee concerned
20	20	A BILL
21	21	To ensure that prior authorization medical decisions under
22	22	Medicare are determined by physicians.
23	23	Be it enacted by the Senate and House of Representa-1
24	24	tives of the United States of America in Congress assembled, 2
25	25	SECTION 1. SHORT TITLE. 3
26	26	This Act may be cited as the ‘‘Reducing Medically 4
27	27	Unnecessary Delays in Care Act of 2025’’. 5
28	28	SEC. 2. DEFINITIONS. 6
29	29	In this Act: 7
30	30	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
31	31	ssavage on LAPJG3WLY3PROD with BILLS 2
32	32	•HR 2433 IH
33	33	(1) ADVERSE DETERMINATION .—The term ‘‘ad-1
34	34	verse determination’’ means a decision by a medicare 2
35	35	administrative contractor, Medicare Advantage plan, 3
36	36	or prescription drug plan that administers prior au-4
37	37	thorization programs under the Medicare program 5
38	38	under title XVIII of the Social Security Act or such 6
39	39	plan that the health care services furnished or pro-7
40	40	posed to be furnished to an individual entitled to 8
41	41	benefits or enrolled under the Medicare program are 9
42	42	not medically necessary, or are experimental or in-10
43	43	vestigational; and benefit coverage under such pro-11
44	44	gram or plan for such services is therefore denied, 12
45	45	reduced, or terminated. 13
46	46	(2) A
47	47	UTHORIZATION.—The term ‘‘authoriza-14
48	48	tion’’ means a determination by a medicare adminis-15
49	49	trative contractor, Medicare Advantage plan, or pre-16
50	50	scription drug plan that administers prior authoriza-17
51	51	tion programs under the Medicare program under 18
52	52	title XVIII of the Social Security Act or such plan 19
53	53	that a health care service has been reviewed and, 20
54	54	based on the information provided, satisfies the utili-21
55	55	zation review entity’s requirements for medical ne-22
56	56	cessity and appropriateness and that payment will 23
57	57	be made under the Medicare program under title 24
58	58	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
59	59	ssavage on LAPJG3WLY3PROD with BILLS 3
60	60	•HR 2433 IH
61	61	XVIII of the Social Security Act or such plan for 1
62	62	that health care service. 2
63	63	(3) C
64	64	LINICAL CRITERIA.—The term ‘‘clinical 3
65	65	criteria’’ means the written policies, written screen-4
66	66	ing procedures, drug formularies, or lists of covered 5
67	67	drugs, decision rules, decision abstracts, clinical pro-6
68	68	tocols, practice guidelines, and medical protocols 7
69	69	used by a medicare administrative contractor, Medi-8
70	70	care Advantage plan, or prescription drug plan to 9
71	71	determine the necessity and appropriateness of 10
72	72	health care services. 11
73	73	(4) F
74	74	INAL ADVERSE DETERMINATION .—The 12
75	75	term ‘‘final adverse determination’’ means an ad-13
76	76	verse determination that has been upheld by a medi-14
77	77	care administrative contractor, Medicare Advantage 15
78	78	plan, or prescription drug plan at the completion of 16
79	79	the contractor’s appeals process. 17
80	80	(5) H
81	81	EALTH CARE SERVICE.—The term ‘‘health 18
82	82	care service’’ means a health care item, service, pro-19
83	83	cedure, treatment, or prescription drug provided by 20
84	84	a facility licensed in the State involved or provided 21
85	85	by a doctor of medicine, a doctor of osteopathic med-22
86	86	icine, or a health care professional licensed in such 23
87	87	State. 24
88	88	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
89	89	ssavage on LAPJG3WLY3PROD with BILLS 4
90	90	•HR 2433 IH
91	91	(6) MEDICALLY NECESSARY HEALTH CARE 1
92	92	SERVICE.—The term ‘‘medically necessary health 2
93	93	care services’’ means health care services that a pru-3
94	94	dent physician would provide to a patient for the 4
95	95	purpose of preventing, diagnosing, or treating an ill-5
96	96	ness, injury, disease, or its symptoms in a manner 6
97	97	that is— 7
98	98	(A) in accordance with generally accepted 8
99	99	standards of medical practice; 9
100	100	(B) clinically appropriate in terms of type, 10
101	101	frequency, extent, site, and duration; and 11
102	102	(C) not primarily for the economic benefit 12
103	103	of the health plans and purchasers or for the 13
104	104	convenience of the patient, treating physician, 14
105	105	or other health care provider. 15
106	106	(7) M
107	107	EDICARE ADMINISTRATIVE CON -16
108	108	TRACTOR.—The term ‘‘medicare administrative con-17
109	109	tractor’’ means a medicare administrative contractor 18
110	110	with a contract under section 1874A of the Social 19
111	111	Security Act (42 U.S.C. 1395kk–1). 20
112	112	(8) M
113	113	EDICARE ADVANTAGE PLAN .—The term 21
114	114	‘‘Medicare Advantage plan’’ means a Medicare Ad-22
115	115	vantage plan under part C of title XVIII of the So-23
116	116	cial Security Act. 24
117	117	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
118	118	ssavage on LAPJG3WLY3PROD with BILLS 5
119	119	•HR 2433 IH
120	120	(9) P REAUTHORIZATION.—The term 1
121	121	‘‘preauthorization’’— 2
122	122	(A) means the process by which a medicare 3
123	123	administrative contractor, Medicare Advantage 4
124	124	plan, or prescription drug plan determines the 5
125	125	medical necessity or medical appropriateness of 6
126	126	health care services for which benefits are oth-7
127	127	erwise provided under the Medicare program 8
128	128	under title XVIII of the Social Security Act or 9
129	129	such plan prior to the rendering of such health 10
130	130	care services, including preadmission review, 11
131	131	pretreatment review, utilization, and case man-12
132	132	agement; and 13
133	133	(B) includes any requirement that a pa-14
134	134	tient or health care provider notify the Centers 15
135	135	for Medicare & Medicaid Services prior to pro-16
136	136	viding a health care service. 17
137	137	(10) P
138	138	RESCRIPTION DRUG PLAN .—The term 18
139	139	‘‘prescription drug plan’’ means a prescription drug 19
140	140	plan under part D of title XVIII of the Social Secu-20
141	141	rity Act. 21
142	142	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
143	143	ssavage on LAPJG3WLY3PROD with BILLS 6
144	144	•HR 2433 IH
145	145	SEC. 3. CONTRACT REQUIREMENTS FOR PRIOR AUTHOR-1
146	146	IZATION MEDICAL DECISIONS FOR MEDI-2
147	147	CARE ADMINISTRATIVE CONTRACTORS, 3
148	148	MEDICARE ADVANTAGE PLANS, AND PRE-4
149	149	SCRIPTION DRUG PLANS. 5
150	150	Any contract that applies on or after the date that 6
151	151	is 90 days after the date of the enactment of this Act, 7
152	152	between the Secretary of Health and Human Services and 8
153	153	a medicare administrative contractor under section 1874A 9
154	154	of the Social Security Act, a Medicare Advantage organi-10
155	155	zation under section 1857 of such Act with respect to the 11
156	156	offering of a Medicare Advantage plan, or a PDP sponsor 12
157	157	under section 1860D–12 of such Act with respect to the 13
158	158	offering of a prescription drug plan shall require such 14
159	159	medicare administrative contractor, Medicare Advantage 15
160	160	plan, or prescription drug plan, respectively, to comply 16
161	161	with each of the following requirements: 17
162	162	(1) M
163	163	EDICAL NECESSITY .—Any restriction, 18
164	164	preauthorization, adverse determination, or final ad-19
165	165	verse determination that the medicare administrative 20
166	166	contractor, Medicare Advantage plan, or prescription 21
167	167	drug plan, respectively, places on the provision of a 22
168	168	health care service for the purposes of coverage or 23
169	169	payment of such service under the Medicare pro-24
170	170	gram under title XVIII of such Act, or under such 25
171	171	plan, shall be based on the medical necessity or ap-26
172	172	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
173	173	ssavage on LAPJG3WLY3PROD with BILLS 7
174	174	•HR 2433 IH
175	175	propriateness of such service and on written clinical 1
176	176	criteria. 2
177	177	(2) E
178	178	VIDENCE-BASED STANDARDS.—If no inde-3
179	179	pendently developed evidence-based standards exist 4
180	180	for a particular health care service, the medicare ad-5
181	181	ministrative contractor, Medicare Advantage plan, or 6
182	182	prescription drug plan, respectively, may not deny 7
183	183	coverage of the health care service based solely on 8
184	184	the grounds that the health care service does not 9
185	185	meet an evidence-based standard. 10
186	186	(3) I
187	187	NPUT FROM PHYSICIANS .—Prior to estab-11
188	188	lishing, or substantially or materially altering, writ-12
189	189	ten clinical criteria for purpose of preauthorization 13
190	190	review, the medicare administrative contractor, 14
191	191	Medicare Advantage plan, or prescription drug plan, 15
192	192	respectively, shall obtain input from actively prac-16
193	193	ticing physicians within the service area where the 17
194	194	written clinical criteria are to be employed. Such 18
195	195	physicians must represent major areas of specialty 19
196	196	and be certified by the boards of the American 20
197	197	Board of Medical Specialties or the American Osteo-21
198	198	pathic Association. The medicare administrative con-22
199	199	tractor, Medicare Advantage plan, or prescription 23
200	200	drug plan shall seek input from physicians who are 24
201	201	not employees of the medicare administrative con-25
202	202	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
203	203	ssavage on LAPJG3WLY3PROD with BILLS 8
204	204	•HR 2433 IH
205	205	tractor, Medicare Advantage plan, or prescription 1
206	206	drug plan. 2
207	207	(4) W
208	208	RITTEN CLINICAL CRITERIA .—The medi-3
209	209	care administrative contractor, Medicare Advantage 4
210	210	plan, or prescription drug plan, respectively, shall 5
211	211	apply written clinical criteria for the purpose of 6
212	212	preauthorization review consistently. Such written 7
213	213	clinical criteria must— 8
214	214	(A) be based on nationally recognized 9
215	215	standards; 10
216	216	(B) be developed in accordance with the 11
217	217	current standards of national accreditation enti-12
218	218	ties; 13
219	219	(C) reflect community standards of care; 14
220	220	(D) ensure quality of care and access to 15
221	221	needed health care services; 16
222	222	(E) be evidence based; 17
223	223	(F) be sufficiently flexible to allow devi-18
224	224	ations from norms when justified on case-by- 19
225	225	case bases; and 20
226	226	(G) be evaluated and updated if necessary 21
227	227	at least annually. 22
228	228	(5) W
229	229	EBSITE POSTING.—The medicare adminis-23
230	230	trative contractor, Medicare Advantage plan, or pre-24
231	231	scription drug plan, respectively, shall make any cur-25
232	232	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
233	233	ssavage on LAPJG3WLY3PROD with BILLS 9
234	234	•HR 2433 IH
235	235	rent preauthorization requirements and restrictions 1
236	236	readily accessible on its website to subscribers, 2
237	237	health care providers, and the general public. This 3
238	238	includes the written clinical criteria. Such require-4
239	239	ments must be described in detail but also in easily 5
240	240	understandable language. 6
241	241	(6) N
242	242	OTICE REQUIRED FOR NEW REQUIRE -7
243	243	MENTS OR RESTRICTIONS .—If the medicare adminis-8
244	244	trative contractor, Medicare Advantage plan, or pre-9
245	245	scription drug plan, respectively, decides to imple-10
246	246	ment a new preauthorization requirement or restric-11
247	247	tion, or amend an existing requirement or restric-12
248	248	tion, the medicare administrative contractor, Medi-13
249	249	care Advantage plan, or prescription drug plan shall 14
250	250	provide contracted health care providers written no-15
251	251	tice of the new or amended requirement or amend-16
252	252	ment no less than 60 days before the requirement or 17
253	253	restriction is implemented and shall ensure that the 18
254	254	new or amended requirement has been updated on 19
255	255	the medicare administrative contractor, Medicare 20
256	256	Advantage plan, or prescription drug plan’s website. 21
257	257	(7) A
258	258	VAILABILITY OF DETERMINATIONS .—The 22
259	259	medicare administrative contractor, Medicare Advan-23
260	260	tage plan, or prescription drug plan, respectively, 24
261	261	utilizing preauthorization shall make statistics avail-25
262	262	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
263	263	ssavage on LAPJG3WLY3PROD with BILLS 10
264	264	•HR 2433 IH
265	265	able regarding preauthorization approvals and deni-1
266	266	als for coverage or payment of health care services 2
267	267	under the Medicare program under title XVIII of 3
268	268	the Social Security Act or such plan on their website 4
269	269	in a readily accessible format. The medicare admin-5
270	270	istrative contractor, Medicare Advantage plan, or 6
271	271	prescription drug plan shall include categories for— 7
272	272	(A) physician specialty; 8
273	273	(B) medication or diagnostic test/proce-9
274	274	dure; 10
275	275	(C) indication offered; and 11
276	276	(D) reason for denial. 12
277	277	(8) D
278	278	ETERMINATIONS MADE BY PHYSICIANS .— 13
279	279	The medicare administrative contractor, Medicare 14
280	280	Advantage plan, or prescription drug plan, respec-15
281	281	tively, shall ensure that all preauthorizations and ad-16
282	282	verse determinations are made by a physician who 17
283	283	possesses a current and valid non-restricted license 18
284	284	to practice medicine in a State, and must be board 19
285	285	certified or eligible under the rules and guidelines of 20
286	286	the American Board of Medical Specialties or Amer-21
287	287	ican Osteopathic Association in the same specialty 22
288	288	as the health care provider who typically manages 23
289	289	the medical condition or disease or provides the 24
290	290	health care service. The physician must make the 25
291	291	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H2433.IH H2433
292	292	ssavage on LAPJG3WLY3PROD with BILLS 11
293	293	•HR 2433 IH
294	294	adverse determination under the clinical direction of 1
295	295	one of the medicare administrative contractor’s, 2
296	296	Medicare Advantage plan’s, or prescription drug 3
297	297	plan’s medical directors who is responsible for the 4
298	298	provision of health care services and who is licensed 5
299	299	in such State. 6
300	300	Æ
301	301	VerDate Sep 11 2014 00:13 Apr 03, 2025 Jkt 059200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6301 E:\BILLS\H2433.IH H2433
302	302	ssavage on LAPJG3WLY3PROD with BILLS