Medicare insurers must now justify coverage denials to doctors
H.R. 2433 — Reducing Medically Unnecessary Delays in Care Act of 2025 · Filed by Mark Green (R-TN) · 16 cosponsors · Introduced Mar 27, 2025 · Referred to committee
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What it does
This bill requires Medicare insurers and drug plans to base prior authorization decisions (denials of coverage) on written clinical criteria developed with input from practicing physicians, make those criteria publicly available, and ensure that all coverage denials are made by licensed physicians in the relevant specialty. It aims to reduce delays in patient care by requiring 60-day notice before new restrictions take effect and mandating transparency about approval/denial rates.
Why we flagged it
The bill's core mechanism is procedural reform of Medicare prior authorization: it mandates physician involvement, clinical evidence standards, public disclosure, and advance notice. It does not eliminate prior authorization but restructures it to prioritize medical judgment over administrative cost-control.
What the text implies
- May increase administrative burden on Medicare Advantage plans and drug plans, potentially raising their costs and affecting premium pricing for beneficiaries.
- Physician-led review requirement may slow some approvals if qualified specialists are unavailable, creating a different type of delay than the bill aims to prevent.
The full analysis lists 4 implications of this text.
Who stands to gain
Medicare Advantage plans (HUM, UNH, CI, ANTM); Prescription drug plan sponsors; Healthcare providers and physicians (reduced administrative friction)