H.R.2433 - Reducing Medically Unnecessary Delays in Care Act of 2025 (119th Congress)
Summary
H.R.2433, the Reducing Medically Unnecessary Delays in Care Act of 2025, aims to ensure that prior authorization decisions under Medicare are made by physicians. This bill seeks to establish requirements for Medicare Administrative Contractors, Medicare Advantage Plans, and Prescription Drug Plans regarding prior authorization processes.
The bill defines key terms such as 'adverse determination,' 'authorization,' and 'medically necessary health care service.' It mandates that any restrictions or denials of coverage be based on medical necessity and written clinical criteria.
Furthermore, it requires input from practicing physicians when establishing or altering clinical criteria and emphasizes transparency by requiring the posting of preauthorization requirements on websites.
Expected Effects
The likely effect of this bill is to increase physician involvement in prior authorization decisions within Medicare. This could lead to fewer denials of medically necessary care and reduced administrative burdens for both patients and healthcare providers.
It may also increase costs for Medicare Advantage plans and prescription drug plans, potentially leading to higher premiums. The bill also aims to standardize and make transparent the criteria used for prior authorizations.
Potential Benefits
- Reduced delays in care: By ensuring physician involvement, the bill aims to minimize medically unnecessary delays caused by administrative hurdles.
- Improved access to necessary treatments: The focus on medical necessity could lead to better alignment between coverage decisions and patient needs.
- Increased transparency: Requiring the posting of preauthorization requirements on websites will make the process more transparent for patients and providers.
- Standardized criteria: The bill promotes the use of nationally recognized and evidence-based standards for preauthorization review.
- Greater physician autonomy: The bill empowers physicians to make medical decisions based on their professional judgment.
Most Benefited Areas:
Potential Disadvantages
- Potential for increased healthcare costs: More physician involvement and fewer denials could lead to higher costs for Medicare and its beneficiaries.
- Administrative burden on physicians: Participating in the development of clinical criteria could create an additional administrative burden for physicians.
- Possible inconsistencies in application: Despite the emphasis on standardized criteria, variations in interpretation and application could still occur.
- Risk of unintended consequences: The bill's requirements could have unintended consequences for the efficiency and effectiveness of Medicare programs.
- Potential for litigation: Disputes over medical necessity and appropriateness could lead to increased litigation.
Most Disadvantaged Areas:
Constitutional Alignment
The bill appears to align with the general welfare clause of the Constitution, as it aims to improve healthcare access and reduce delays in care for Medicare beneficiaries. The Constitution grants Congress the power to make laws necessary and proper for carrying out its enumerated powers, including providing for the general welfare through programs like Medicare. The bill does not appear to infringe upon any specific constitutional rights or limitations.
However, the Tenth Amendment reserves powers not delegated to the federal government to the states or the people. Some may argue that the federal government's regulation of Medicare Advantage plans and prescription drug plans intrudes upon areas traditionally regulated by states, such as insurance regulation. However, the federal government's authority to regulate Medicare is well-established.
Overall, the bill seems to operate within the bounds of constitutional authority, particularly concerning the federal government's role in providing for the general welfare through Medicare.
Impact Assessment: Things You Care About ⓘ
This action has been evaluated across 19 key areas that matter to you. Scores range from 1 (highly disadvantageous) to 5 (highly beneficial).