# Plain Language Summary: Reducing Medically Unnecessary Delays in Care Act of 2025

Right now, when Medicare patients need certain medical treatments or medications, insurance companies often require "prior authorization"—basically, they make you get approval before you can receive the care. This bill aims to make sure that when these approval decisions are made, they're actually made by real doctors, not just insurance company bureaucrats following rigid rules.

The core requirement is straightforward: any decision to deny or delay Medicare coverage for a medical service must be made by a licensed physician who is board-certified in the relevant medical specialty. That doctor also has to follow written clinical guidelines that are based on actual medical evidence, not just what saves the insurance company money. Currently, insurance companies can use non-physicians or outdated criteria to make these decisions, which can result in patients being denied treatments their own doctors think they need.

The bill also requires insurance companies to be more transparent about how they make these decisions. They have to post their approval and denial rates online, broken down by doctor specialty and type of treatment, so patients and doctors can see if certain treatments are being unfairly blocked. Insurance companies also have to get input from independent doctors in the community before creating or changing their approval rules, and they must give doctors at least 60 days' notice before implementing new restrictions. Additionally, insurance companies can't deny coverage just because a treatment is newer or doesn't fit their standard guidelines if there's a legitimate medical reason for it—the rules have to be flexible enough to allow exceptions when doctors justify them on a case-by-case basis.

Reducing Medically Unnecessary Delays in Care Act of 2025

Reducing Medically Unnecessary Delays in Care Act of 2025This bill requires Medicare coverage decisions, including prior authorization requirements and adverse coverage decisions, to be based on written clinical criteria that is developed in consultation with physicians.