Medicare Prior Authorization Reform

Summary#

The Reducing Medically Unnecessary Delays in Care Act of 2025 would create new requirements for certain contracts between the U.S. Department of Health and Human Services and Medicare contractors and plans. Its stated goal is to have physicians make Medicare prior-authorization decisions; the bill does not guarantee that care will be approved or that delays will end.

  • For contracts applying 90 days or more after enactment, Medicare administrative contractors, Medicare Advantage plans and Part D prescription drug plans would have to base restrictions and decisions on medical necessity or appropriateness and written clinical criteria.
  • They would have to use clinical criteria that meet listed standards, apply them consistently, review them at least annually and get input from qualifying practicing physicians before establishing or materially changing them.
  • A physician licensed in a state would have to make every prior-authorization decision and adverse determination. The physician must meet a specialty requirement; adverse determinations must also be made under the clinical direction of a medical director licensed in that state.
  • Plans and contractors would have to post current requirements and criteria, give contracted providers at least 60 days’ written notice of new or amended requirements, and post statistics on approvals and denials in specified categories.

What it means for you#

  • People with Medicare: Prior-authorization rules and decisions would have to follow the bill’s standards if the relevant contract is covered. The bill does not require approval of a particular service, change Medicare eligibility, or create a new appeal process.
  • Doctors and other health care providers: Providers would receive at least 60 days’ notice of new or changed requirements. Physician input would be required when criteria are established or materially changed, but the bill does not require providers to submit every proposed treatment for review.
  • Medicare contractors and plans: They would have to meet the decision-making, criteria, website, notice and statistics requirements. Part D plans are included.
  • Current-law comparison: The supplied materials do not include the Social Security Act or related current rules, so it is not possible to verify which of these requirements already exist or how the bill would interact with them.

Money#

No cost information is in the available material.

  • The bill would require covered contractors and plans to provide physician decision-makers and medical-director oversight, as well as maintain criteria, notices and online information. It gives no staffing or cost estimate.
  • It does not specify a new appropriation, fee, fine or payment to patients or providers.

What is unclear#

  • The bill does not set rules for urgent cases, decision timelines, appeals, enforcement or penalties for failing to comply.
  • It does not explain how much physician input is enough, or how to identify physicians who represent “major areas of specialty.”
  • Terms such as “substantially or materially altering” criteria and “independently developed evidence-based standards” are not defined in the bill.
  • The bill does not specify how the required approval and denial statistics must be calculated or how often they must be updated.
  • It is unclear how the requirements would apply to contracts already in force when the 90-day period ends. The bill is at the introduced stage, so passage and an effective date are not assured.

Case for#

  • The bill appears intended to address prior-authorization decisions that may delay or restrict medically necessary care.
  • Requiring a physician with relevant specialty credentials to make decisions could bring medical expertise directly into the review.
  • Written, publicly posted criteria and advance notice could make requirements easier for providers and patients to understand.
  • Public statistics could make approval and denial patterns more visible.

Case against#

  • Requiring physicians to make all prior-authorization decisions could require more physician staffing; the bill provides no estimate of the cost or whether enough qualifying physicians would be available.
  • The bill sets standards for criteria but leaves important terms and procedures undefined, which could lead to inconsistent application.
  • The bill does not set decision deadlines or create an urgent-care process, so it does not ensure that reviews become faster.
  • The added requirements could increase administrative work for plans, contractors and providers, but the bill does not assess that burden.