Bill > HR2433

This bill aims to improve the prior authorization process for Medicare by establishing new requirements for Medicare Administrative Contractors, Medicare Advantage Plans, and Prescription Drug Plans. The bill mandates that medical necessity determinations must be based on written clinical criteria developed with input from actively practicing physicians representing major medical specialties. These clinical criteria must be evidence-based, flexible, nationally recognized, and updated at least annually. The bill requires that all preauthorization and adverse determination decisions be made by licensed, board-certified physicians in the relevant medical specialty. Additionally, these organizations must make their preauthorization requirements, clinical criteria, and statistical data on approvals and denials publicly accessible on their websites. The bill ensures that if no independent evidence-based standards exist for a specific health care service, coverage cannot be denied solely on those grounds. Providers must receive at least 60 days' notice before any new preauthorization requirements are implemented, and the determination process must prioritize medical necessity and patient care over economic benefits or convenience.

Budget and Finance

https://www.congress.gov/bill/119th-congress/house-bill/2433/all-info